Queensland Health Queensland Health

Improvement | Transparency | Patient Safety | Clinician Leadership | Innovation

Statewide Cardiac Clinical Network Queensland Cardiac Outcomes Registry 2017 Annual Report

Clinical Excellence Division Creating solutions for better healthcare Interventional Cardiology Audit

Contents

1 Message from the SCCN Chair 1 Interventional Cardiology Audit 2 Introduction 2 7 Message from the QCOR Interventional Cardiology Committee Chair IC 3 3 Executive summary 4 8 Key findings IC 4 4 Acknowledgements and authors 5 9 Participating sites IC 5 5 QCOR Committees 7 9.1 Statewide IC 6 6 Future plans 9 9.2 Cairns Hospital IC 7 9.3 The Townsville Hospital IC 7 9.4 Mackay Base Hospital IC 8 9.5 Sunshine Coast University Hospital IC 8 9.6 The Prince Charles Hospital IC 9 9.7 Royal Brisbane and Women’s Hospital IC 9 9.8 Princess Alexandra Hospital IC 10 9.9 Gold Coast University Hospital IC 10

10 Total cases IC 11 10.1 Procedure type IC 11 10.2 Total cases by diagnosis IC 12

11 Patient characteristics IC 13 11.1 Age and gender IC 13 11.2 Body mass index IC 14 11.3 Place of residence IC 15 11.4 Aboriginal and Torres Strait Islander status IC 17

12 Care and treatment of PCI patients IC 19 12.1 Admission status IC 19 12.2 Access route IC 21 12.3 Vessels treated IC 22 12.4 Stent type IC 23 12.5 NSTEMI IC 24 12.6 PCI following presentation with STEMI IC 27

13 Clinical indicators IC 29 13.1 Mortality outcomes IC 30 13.2 STEMI less than 6 hours from symptom onset – time to reperfusion IC 34 13.3 NSTEMI – time to angiography IC 39 13.4 Major procedural complications IC 41 13.5 Safe radiation doses IC 42

14 Conclusions IC 43

This report is available online at: 15 Recommendations IC 44 https://clinicalexcellence.qld.gov.au/priority-areas/ 16 Supplement: Structural heart disease IC 45 clinician-engagement/statewide-clinical-networks/ 16.1 Participating sites IC 45 cardiac 16.2 Patient characteristics IC 46 For all enquiries, please contact the Statewide 16.3 Care and treatment of SHD patients IC 47 Cardiac Clinical Informatics Unit at: 16.4 Patient outcomes IC 50 [email protected] Cardiac Surgery Audit Electrophysiology and Pacing Audit 17 Message from the QCOR Cardiothoracic 28 Message from the QCOR Electrophysiology and Committee Chair CS 3 Pacing Committee Chair EP 3 18 Key findings CS 4 29 Key findings EP 4 19 Participating sites CS 5 30 Participating sites EP 5 20 Case totals CS 7 31 Case totals EP 8 20.1 Total cases CS 7 31.1 Total cases EP 8 20.2 Cases by category CS 8 31.2 Cases by category EP 9

21 Patient characteristics CS 9 32 Patient characteristics EP 10 21.1 Age and gender CS 9 32.1 Age and gender EP 10 21.2 Body mass index CS 11 32.2 Body mass index EP 12 21.3 Aboriginal and Torres Strait Islander 32.3 Aboriginal and Torres Strait Islander status CS 12 status EP 13

22 Risk factor profile CS 13 33 Risk factors and comorbidities EP 14 22.1 Smoking history CS 13 33.1 Coronary artery disease EP 14 22.2 Diabetes CS 13 33.2 Family history of sudden cardiac death EP 14 22.3 Hypertension CS 14 33.3 Smoking history EP 15 22.4 Statin therapy CS 14 33.4 Diabetes EP 15 22.5 Renal impairment CS 14 33.5 Hypertension EP 15 22.6 Severe renal dysfunction CS 15 33.6 Dyslipidaemia EP 16 22.7 Left ventricular function CS 15 33.7 Atrial arrhythmia history EP 16 22.8 Summary of risk factors CS 16 33.8 Heart failure EP 16 33.9 Valvular heart disease EP 17 23 Care and treatment of patients CS 17 23.1 Admission status CS 17 33.10 Other cardiovascular disease and co-morbidities EP 17 23.2 Day of surgery admission CS 18 33.11 Renal impairment EP 18 23.3 Coronary artery bypass grafts CS 19 33.12 Anticoagulation EP 18 23.4 Aortic surgery CS 21 33.13 LV function EP 18 23.5 Valve surgery CS 22 23.6 Other cardiac surgery CS 26 34 Care and treatment of patients EP 19 23.7 Blood product usage CS 27 34.1 Urgency category EP 19 34.2 Admission source EP 20 24 Outcomes CS 28 34.3 Admission source and urgency category EP 21 24.1 Risk prediction models CS 28 34.4 Device procedures EP 22 25 Conclusions CS 35 34.5 Electrophysiology studies/ablations EP 23 34.6 Other procedures EP 31 26 Recommendations CS 35 27 Supplement: Infective endocarditis CS 36 35 Procedural complications EP 32 27.1 Patient characteristics CS 38 36 Conclusions EP 34 27.2 Care and treatment of infective endocarditis patients CS 39 37 Recommendations EP 34 27.3 Comorbidities CS 41 27.4 Microbiology CS 41 27.5 Patient outcomes CS 42 27.6 Discussion CS 43 Cardiac Rehabilitation Audit Heart Failure Support Services Audit 38 Message from the QCOR Cardiac Rehabilitation 48 Message from the Heart Failure Services Committee Chair CR 3 Steering Committee Chairs HF 3 39 Key findings CR 5 49 Key findings HF 4 40 Participating sites CR 6 50 Participating sites HF 6 41 Total referrals CR 8 51 New referrals HF 9 51.1 Location of referrals HF 9 42 Patient characteristics CR 10 42.1 Age and gender CR 10 51.2 Referral source HF 11 42.2 Aboriginal and Torres Strait Islander status CR 11 52 Patient characteristics HF 12 52.1 Age HF 12 43 Total assessments CR 13 52.2 Gender HF 13 44 Clinical presentation CR 14 52.3 Aboriginal and Torres Strait Islander 44.1 Diagnosis CR 14 status HF 15 44.2 Risk factors and comorbidities CR 15 52.4 Classification of heart failure by left 44.3 Current medications CR 19 ventricular ejection fraction HF 16 52.5 Summary of patient characteristics HF 18 45 Clinical indicators CR 20 45.1 Timely referral CR 21 53 Clinical indicators HF 19 45.2 Timely assessment CR 22 53.1 First clinical review HF 20 53.2 Left ventricular ejection fraction (LVEF) 46 Conclusions CR 24 assessed within 2 years of referral to 47 Recommendations CR 24 HFSS HF 24 53.3 Prescription of ACEI or ARB for patients with HFrEF HF 26 53.4 Prescription of guideline recommended beta blockers for HFrEF HF 30 53.5 Beta blocker titration HF 34 53.6 Summary of clinical indicators HF 40

54 Patient outcomes HF 42 54.1 Methods HF 42 54.2 Findings HF 43 54.3 Discussion HF 47

55 Conclusions HF 48 56 Recommendations HF 49 57 Appendix: List of ICD10-AM Codes HF 50 Reference and Glossary

58 References i 59 Glossary iv 60 Upcoming initiatives v Interventional Cardiology Audit

Figures

Figure A: Operational structure 2 Interventional Cardiology Audit Figure B: QCOR 2017 infographic 3 Figure 1: PCI cases by residential postcode IC 6 Figure 2: Cairns Hospital IC 7 Figure 3: The Townsville Hospital IC 7 Figure 4: Mackay Base Hospital IC 8 Figure 5: Sunshine Coast University Hospital IC 8 Figure 6: The Prince Charles Hospital IC 9 Figure 7: Royal Brisbane and Women’s Hospital IC 9 Figure 8: Princess Alexandra Hospital IC 10 Figure 9: Gold Coast University Hospital IC 10 Figure 10: Proportion of all PCI cases by gender and age group IC 13 Figure 11: Proportion of all PCI cases by body mass index category IC 14 Figure 12: Queensland PCI cases by distance to nearest PCI facility IC 16 Figure 13: Proportion of all PCI cases by identified Aboriginal and Torres Strait Islander status IC 17 Figure 14: Proportion of all PCI cases by age group and Aboriginal and Torres Strait Islander status IC 18 Figure 15: Proportion of all PCI cases by admission status IC 20 Figure 16: Proportion of cases including at least one stent by site and stent type IC 23 Figure 17: Proportion of NSTEMI direct presenters receiving angiography within 72 hours, 2015 to 2017 IC 25 Figure 18: Proportion of NSTEMI interhospital transfers receiving angiography within 72 hours, 2015 to 2017 IC 26 Figure 19: Proportion of STEMI cases by first medical contact IC 27 Figure 20: Comparison of observed and predicted mortality rates by site IC 31 Figure 21: Comparison of observed and predicted mortality rates by site, excluding salvage IC 31 Figure 22: STEMI presenting within 6 hours of symptom onset – median first diagnostic ECG to first device time by admission pathway IC 35 Figure 23: Proportion of STEMI cases (<6 hours of symptom onset) where time from first diagnostic ECG to reperfusion met 90 minute target, 2015–2017 IC 36 Figure 24: STEMI under 6 hours pre-hospital component breakdown – QAS direct to PCI facility IC 37 Figure 25: Proportion of cases where door to device ≤60 minutes was met for STEMI presenting within 6 hours of symptom onset, 2015–2017 IC 38 Figure 26: Proportion of NSTEMI cases meeting time to angiography target of 72 hours, 2015–2017 IC 40 Figure 27: Documented immediate major procedural complications by site IC 41 Interventional Cardiology Audit

Interventional Cardiology Audit Cardiac Surgery Audit Figure 1: Proportion of all SHD cases by gender Figure 1: Cardiac surgery cases by residential and age group IC 46 postcode CS 5 Figure 2: Proportion of all transcatheter valvular Figure 2: The Townsville Hospital CS 6 interventions by valve type IC 48 Figure 3: The Prince Charles Hospital CS 6 Figure 4: Princess Alexandra Hospital CS 6 Figure 5: Gold Coast University Hospital CS 6 Figure 6: Proportion of cases by site and surgery category CS 8 Figure 7: Proportion of all cases by age group and gender CS 9 Figure 8: Proportion of cases by gender and surgery category CS 10 Figure 9: Proportion of cases by BMI and surgery category CS 11 Figure 10: Proportion of cases by identified Aboriginal and Torres Strait Islander status and surgery category CS 12 Figure 11: Proportion of cases by smoking status and surgery category CS 13 Figure 12: Proportion of cases by diabetes status and surgery category CS 13 Figure 13: Proportion of cases by hypertension status and surgery category CS 14 Figure 14: Proportion of cases by statin therapy status and surgery category CS 14 Figure 15: Proportion of cases by renal impairment status and surgery category CS 14 Figure 16: Proportion of cases by severe renal dysfunction status and surgery category CS 15 Figure 17: Proportion of cases by LV dysfunction category and surgery category CS 15 Figure 18: Proportion of cases by admission status and surgery category CS 17 Figure 19: Proportion of elective cases for DOSA by surgery category CS 18 Figure 20: Number of diseased vessels CS 19 Figure 21: Proportion of diseased vessels by conduits used CS 20 Figure 22: Proportion of valve surgery cases by valve CS 22 Figure 23: Valve surgery category by valve CS 24 Figure 24: Proportion of valve replacements by valve prosthesis category and valve type CS 25 Figure 25: Blood product usage by admission status CS 27 Figure 26: EuroSCORE CS 29 Figure 27: ANZSCTS General Score CS 29 Figure 28: STS (death) CS 29 Figure 29: CABG CS 29 Figure 30: CVA CS 30 Figure 31: Renal failure CS 30 Figure 32: Ventilation >24 hours CS 30 Figure 33: Reoperation CS 30 Cardiac Surgery Audit Supplement Figure 34: Deep sternal wound infection CS 31 Figure 1: Infective endocarditis cases by Figure 35: Major morbidity CS 31 residential postcode CS 37 Figure 36: LOS <6 days CS 32 Figure 2: Infective endocarditis cases by age Figure 37: LOS >14 days CS 32 category CS 38 Figure 38: Failure to rescue CS 33 Figure 3: Infective endocarditis cases by surgery Figure 39: Comparison of 2016 deep sternal category CS 39 wound infection rates, pre vs. post Figure 4: Infective endocarditis cases by type of audit CS 34 valve CS 40 Electrophysiology and Pacing Audit

Electrophysiology and Pacing Audit Cardiac Rehabilitation Audit Figure 1: Electrophysiology and pacing cases by Figure 1: Queensland public CR sites CR 6 residential postcode EP 5 Figure 2: CR inpatient referrals by source and Figure 2: Cairns Hospital EP 6 destination HHS CR 9 Figure 3: The Townsville Hospital EP 6 Figure 3: Referrals by patient gender and age Figure 4: Mackay Base Hospital EP 6 group CR 10 Figure 5: Sunshine Coast University Hospital EP 6 Figure 4: Reasons pre assessment was not Figure 6: The Prince Charles Hospital EP 7 conducted CR 13 Figure 7: Royal Brisbane & Women’s Hospital EP 7 Figure 5: Smoking status by diagnosis category CR 15 Figure 8: Princess Alexandra Hospital EP 7 Figure 6: BMI category by diagnosis category CR 15 Figure 9: Proportion of cases by site and category EP 9 Figure 7: Diabetes by diagnosis category CR 16 Figure 10: Proportion of all cases by age group Figure 8: High blood pressure by diagnosis and gender EP 10 category CR 16 Figure 11: Proportion of cases by gender and Figure 9: Abnormal cholesterol by diagnosis category EP 11 category CR 16 Figure 12: Proportion of cases by BMI and case Figure 10: Family history of cardiovascular disease category EP 12 by diagnosis category CR 17 Figure 13: Proportion of cases by identified Figure 11: Heart failure by diagnosis category CR 17 Aboriginal and Torres Strait Islander Figure 12: Severity of LV dysfunction by diagnosis status and site EP 13 category CR 17 Figure 14: Proportion of cases by coronary artery Figure 13: History of depression by diagnosis disease history and case category EP 14 category CR 18 Figure 15: Proportion of cases by sudden cardiac Figure 14: Activity level by diagnosis category CR 18 death history and case category EP 14 Figure 15: Alcohol consumption by diagnosis Figure 16: Proportion of cases by smoking status category CR 18 and case category EP 15 Figure 17: Proportion of cases by diabetes status and case category EP 15 Figure 18: Proportion of cases by hypertension status and case category EP 15 Figure 19: Proportion of cases by dyslipidaemia history status and case category EP 16 Figure 20: Proportion of cases by atrial arrhythmia history status and case category EP 16 Figure 21: Proportion of cases by heart failure history status and case category EP 16 Figure 22: Proportion of cases by valvular heart disease history and case category EP 17 Figure 23: Proportion of cases by CV disease history/co-morbidity and case category EP 17 Figure 24: Proportion of cases by renal impairment status and case category EP 18 Figure 25: Proportion of cases by anticoagulation status and case category EP 18 Figure 26: Proportion of cases by LV function category and case category EP 18 Figure 27: Proportion of all cases by urgency category, procedure category and site EP 19 Figure 28: Admission source by site EP 20 Figure 29: Admission source by case category EP 20 Figure 30: Complexity of electrophysiology procedures by site EP 24 Figure 31: Ablation type by site EP 25 Figure 32: Proportion of supraventricular arrhythmia requiring ablation EP 29 Figure 33: Proportion of ventricular arrhythmia requiring ablation EP 30 Heart Failure Support Services Audit Upcoming initiatives Figure 1: Heart Failure Support Service (HFSS) Figure C: Concept model for rapid inter-hospital locations HF 7 clinical interpretation of 12-lead ECGs Figure 2: Regional distribution of new referrals HF 10 (CISP ECG Flash Project) v Figure 3: Age groups at referral to a HFSS HF 12 Figure 4: Proportion of referrals to HFSS by gender and age group HF 14 Figure 5: Proportion of HFrEF referrals by gender and age group HF 17 Figure 6: Proportion of HFpEF referrals by gender and age group HF 17 Figure 7: Proportion of inpatients who received first HF upportS Service clinical review within 2 weeks of hospital discharge or date of referral if received after discharge HF 21 Figure 8: Proportion of non-acute patients who received first HFSS clinical eviewr within 4 weeks of referral HF 23 Figure 9: Proportion of all patients who had LVEF assessed within two years of referral to FSS HF 25 Figure 10: Proportion of patients who were on ACEI or ARB therapy at time of hospital discharge HF 27 Figure 11: Proportion of patients on ACEI or ARB therapy at time of first clinical review by site HF 29 Figure 12: Proportion of patients on guideline recommended beta blocker at hospital discharge by site HF 31 Figure 13: Proportion of patients on guideline recommended beta blocker therapy at first clinical review by site HF 33 Figure 14: Proportion of patients who had a beta blocker titration review conducted within six months by site HF 35 Figure 15: Proportion of patients who achieved target beta blocker dose at time of titration review by site HF 37 Figure 16: Proportion of patients who achieved target beta blocker dose or maximum tolerated dose at time of titration review HF 39 Figure 17: Heart failure survival by gender HF 44 Figure 18: Heart failure survival by age group HF 44 Figure 19: Heart failure survival by phenotype HF 44 Figure 20: Cumulative incidence of all cause rehospitalisation HF 45 Figure 21: Cumulative incidence of heart failure rehospitalisation HF 45 Figure 22: Cumulative incidence of all-cause rehospitalisation or death HF 45 Figure 23: Days alive and out of hospital within one year after hospital discharge HF 46 Figure 24: Days alive and out of hospital within one year of discharge by patient characteristics HF 46 Tables

Interventional Cardiology Audit Interventional Cardiology Audit Supplement Table 1: Participating sites IC 5 Table 1: Total SHD cases by participating site IC 45 Table 2: Proportion of cases with patient Table 2: Median age by gender and procedure esidential postcode within the treating category IC 46 HHS boundaries IC 6 Table 3: Device closure procedures by Table 3: Total number of cases by procedure participating site IC 47 category IC 11 Table 4: Transcatheter valvular interventions by Table 4: Total cases by diagnosis category IC 12 type of valve IC 48 Table 5: PCI cases by diagnosis category IC 12 Table 5: Transcatheter valvular interventions IC 48 Table 6: Median age by gender for all PCI cases IC 13 Table 6: Transcatheter interventional valve Table 7: PCI cases by place of usual residence IC 15 procedures IC 49 Table 8: Queensland PCI cases by distance from Table 7: Transcatheter valve replacement place of residence to nearest PCI facility IC 15 procedures IC 49 Table 9: PCI cases median patient age by gender Table 8: Other structural heart disease and Aboriginal and Torres Strait Islander interventions IC 49 status IC 18 Table 9: All cause unadjusted 30 day mortality Table 10: Diagnostic coronary angiography status IC 19 post SHD intervention by procedure Table 11: PCI cases by site and admission status IC 20 category and site IC 50 Table 12: PCI access route by site IC 21 Table 10: All cause unadjusted 30 day mortality Table 13: Vessels treated by site IC 22 post SHD intervention by site IC 50 Table 14: PCI cases including at least one stent Table 11: All cause unadjusted 30 day and 365 deployed by site and stent type IC 23 day mortality post SHD intervention by site, 2016 IC 50 Table 15: NSTEMI cases IC 24 Table 16: NSTEMI admission source to treating facility IC 24 Table 17: Time to angiography – direct to PCI facility IC 25 Table 18: Time to angiography – interhospital transfers IC 26 Table 19: Proportion of STEMI cases by presentation IC 28 Table 20: All-cause unadjusted mortality within 30 days post PCI by admission status IC 30 Table 21: STEMI mortality up to 30 days in patients who underwent primary PCI IC 33 Table 22: STEMI mortality up to 30 days for patients who underwent a primary PCI nd presented within 6 hours of symptom onset IC 33 Table 23: Definitions for STEMI time to reperfusion IC 34 Table 24: STEMI <6 hours cases ineligible for analysis IC 35 Table 25: First diagnostic ECG (FdECG) to reperfusion for STEMI presenting within 6 hours of symptom onset IC 36 Table 26: Arrival at PCI hospital to first device for STEMI presenting within 6 hours of symptom onset IC 38 Table 27: NSTEMI time to angiography – cases ineligible for analysis IC 39 Table 28: NSTEMI time to angiography by site IC 40 Table 29: All PCI cases by immediate major procedural complication type IC 41 Table 30: Proportion of cases meeting the safe dose threshold by case type IC 42 Cardiac Surgery Audit Cardiac Surgery Audit Supplement Table 1: Participating sites CS 5 Table 1: Infective endocarditis cases by gender Table 2: Procedure counts and surgery category CS 7 and age category CS 38 Table 3: Proportion of cases by surgery category CS 8 Table 2: Infective endocarditis cases by surgery Table 4: Median age by gender and surgery category CS 39 category CS 9 Table 3: Infective endocarditis valve surgery Table 5: Proportion of cases by BMI and surgery cases by type of valve CS 40 category CS 11 Table 4: Valve surgery procedures by valve type CS 40 Table 6: Summary of risk factors by surgery Table 5: Selected comorbidities for patients category CS 16 undergoing valve intervention for Table 7: Summary of combined risk factors by infective endocarditis CS 41 surgery category CS 16 Table 6: Infective endocarditis cases by infection Table 8: Proportion of cases by admission status status CS 41 and surgery category CS 17 Table 7: Active infective endocarditis cases by Table 9: Proportion of DOSA cases by surgery organism type CS 41 category CS 18 Table 8: Active infective endocarditis cases by Table 10: Number of diseased vessels CS 19 native versus prosthetic valve CS 41 Table 11: Mean number of grafts by number of Table 9: All cause 30 day mortality by infection diseased vessels CS 19 status and native versus prosthetic Table 12: Conduits used by number of diseased valve CS 42 vessels CS 20 Table 13: Off pump CABG CS 20 Table 14: Y or T graft used by procedure category CS 20 Table 15: Aortic surgery by procedure type CS 21 Table 16: Aortic surgery cases by pathology type CS 21 Table 17: Valve surgery cases by valve CS 22 Table 18: Valve pathology by valve type CS 23 Table 19: Valve surgery category by valve type CS 24 Table 20: Valve repair surgery by valve type CS 24 Table 21: Valve replacement surgery by valve type CS 25 Table 22: Types of valve prosthesis by valve type CS 25 Table 23: Other cardiac procedures CS 26 Table 24: Blood product usage by admission status CS 27 Electrophysiology and Pacing Audit

Electrophysiology and Pacing Audit Cardiac Rehabilitation Audit Table 1: Participating sites EP 5 Table 1: Participating CR sites by Hospital and Table 2: Total cases by category EP 8 Health Service CR 7 Table 3: Proportion of cases by case category EP 9 Table 2: Referral sources by CR outpatient Table 4: Median age by gender and case program HHS CR 8 category EP 10 Table 3: CR inpatient referrals by source and Table 5: Proportion of cases by gender and destination HHS CR 8 category EP 11 Table 4: Median patient age by gender and Table 6: Proportion of all cases by urgency HHS CR 10 category and site EP 19 Table 5: Aboriginal and Torres Strait Islander Table 7: Admission source by site EP 20 status by HHS CR 11 Table 8: Outpatient cases by urgency category EP 21 Table 6: Total pre-assessments completed by Table 9: Inpatient cases by urgency category EP 21 HHS CR 12 Table 10: Cardiac device case types by site EP 22 Table 7: Assessments by diagnosis and diagnosis category CR 14 Table 11: Electrophysiology study/ablation types by site EP 23 Table 8: Current medications by diagnosis category CR 19 Table 12: Proportion of standard and complex electrophysiology procedures by site EP 24 Table 9: Inpatient referrals created within three days of discharge from a Queensland Table 13: Three dimensional mapping system Health facility CR 21 type by site EP 25 Table 10: Proportion of CR referrals completed Table 14: Ablation type by site EP 25 within 3 days of hospital discharge Table 15: Ablation chamber by site EP 26 by acute site CR 21 Table 16: Supraventricular ablation according to Table 11: Acute referrals assessed within 28 anatomical location EP 27 days of hospital discharge CR 22 Table 17: Ventricular ablation according to Table 12: Proportion of pre assessments anatomical location EP 28 completed within 28 days of hospital Table 18: Supraventricular ablation according to discharge by HHS CR 22 arrhythmia EP 29 Table 13: Proportion of pre assessments Table 19: Ventricular ablation according to completed within 28 days of hospital arrhythmia EP 30 discharge by site CR 23 Table 20: Other procedures EP 31 Table 21: Cardiac device procedure complications EP 32 Table 22: Electrophysiology procedure complications EP 33 Heart Failure Support Services Audit Table 1: Summary of clinical process indicator performance 2017 HF 4 Table 2: Summary of patient outcomes within one year HF 5 Table 3: Activities offered by Queensland HFSS HF 8 Table 4: Distribution of new referrals by HFSS location HF 9 Table 5: Proportion by referral source HF 11 Table 6: Median age (years) of referrals by gender HF 12 Table 7: Number and proportion of referrals to HFSS by gender HF 13 Table 8: Proportion of identified Aboriginal and Torres Strait Islander patients by HFSS HF 15 Table 9: Proportion of patients by heart failure type HF 16 Table 10: Type of heart failure by age, gender, and Aboriginal and Torres Strait Islander status HF 17 Table 11: Summary of patient characteristics HF 18 Table 12: Clinical indicators HF 19 Table 13: Inpatients receiving first HFSS clinical review within 2 weeks of hospital discharge HF 20 Table 14: Non-acute patients receiving first HFSS clinical review within 4 weeks of referral HF 22 Table 15: Patients who had LVEF assessed within two years of referral HF 24 Table 16: Inpatients on ACEI or ARB at time of hospital discharge HF 26 Table 17: Patients on an ACEI or ARB at first clinical review HF 28 Table 18: Patients on guideline recommended beta blocker at hospital discharge HF 30 Table 19: Patients on guideline recommended beta blocker at first clinical review HF 32 Table 20: Patients who had a beta blocker titration review within six months HF 34 Table 21: Patients who achieved target beta blocker dose at time of titration review HF 36 Table 22: Patients who achieved target or maximum tolerated beta blocker dose at time of titration review HF 38 Table 23: Summary of clinical process indicator performance by site HF 41 Table 24: Patient outcome indicators HF 42 Table 25: Eligibility criteria for patient outcome indicators HF 43 Table 26: Cumulative all cause unadjusted mortality rate from 30 to 365 days after index discharge date HF 43 Table 27: Cumulative all cause unadjusted mortality by patient characteristic HF 44 Table 28: Number of rehospitalisations per patient over one year since discharge HF 45 1 Message from the SCCN Chair

Introducing this third annual Queensland Cardiac Outcome Registry Report, I am pleased to announce comprehensive engagement across all 8 public cardiac units in Queensland. This report also profiles the addition of two additional modules to the outcomes registry, electrophysiology, and cardiac rehabilitation.

It is the aim of the registry to provide a comprehensive, quality, patient-based profile of cardiac care in Queensland. The benefits of this registry are becoming clear – not only is the registry seeking to provide data, engagement, and confidence to the physicians, surgeons, and clinicians providing care, but it is also providing clear information to administrators, service planners and consumers of health care that first-rate cardiac processes are “standard care”. The critical element contributing thus far to the success of this project is that it is clinician-led, and broad. Continuing clinician engagement in supply of data, assessment, and interpretation of data and results of treatment is required for ongoing participation in the registry. The project has also facilitated service collaboration and support for the developing non-metropolitan units and early career practitioners.

In evaluating outcomes, it is now commonly acknowledged that short-term (30-day) outcomes are a very incomplete assessment of the adequacy and quality of medical care. In this report, we have begun to examine more extended follow up of heart failure, structural heart and TAVR patients, for the first time reporting 12-month mortality. It is planned to extend these longer-term outcome profiles to angioplasty and cardiac surgery patients. The registry is also actively investigating the addition of patient-reported outcomes as well as parameters such as length of stay, readmission and repeat presentations for care to supplement the panel of quality outcomes.

With data from consecutive years across all cardiac modalities, it will also now be possible to track multiple patient interventions e.g. revascularisation with both angioplasty and cardiac surgery as well as other cardiac procedures and presentation with subsequent events.

During 2017, the adequacy of outreach services has been a focus for the Queensland Cardiac Clinical Network. QCOR data has allowed us to profile the fact that for the larger metropolitan hospital and health services, 40%–50% of the patients treated live outside the boundaries of the metro health services. This has emphasised the need for the Clinical Network to participate in the provision of pathways for time-critical transfer, referral, and assessment as well as the provision of follow up care to consolidate the results of medical intervention.

2017 has been a very successful year in consolidating the efforts of the Queensland Cardiac Outcomes Registry and the report clearly documents the provision of high-quality safe interventions, very comparable with the results of national and international leaders in cardiac care.

In closing, I give my thanks and congratulations to the clinicians who are maintaining the enthusiasm for this important work, in addition to the QCOR technical and administrative staff without whose assistance this work would not be possible.

Dr Paul Garrahy Chair Statewide Cardiac Clinical Network

QCOR Annual Report 2017 Page 1 2 Introduction

The Statewide Cardiac Clinical Network’s, Queensland Cardiac Outcomes Registry (QCOR) provides clinicians high quality, valuable clinical data. QCOR draws on multiple data sources to offer superior levels of analysis for stakeholders to use in both clinical decision-making and service improvement within cardiac services in Queensland. QCOR data collections are governed by clinical committees which report to a central Advisory Committee. This provides direction to the QCOR business unit, the Statewide Cardiac Clinical Informatics Unit (SCCIU). All processes and groups report to the Statewide Cardiac Clinical Network, sponsored by the Clinical Excellence Division within Queensland Health. A high level of clinical engagement ensures the quality and relevance of the data and, more broadly the Registry itself. QCOR committees are continually evolving and have recently moved to more structured operation and governance. The SCCIU is responsible for the operation and data management of the QCOR, including data reporting and analysis for clinicians. It also offers data quality and audit functions. A clinician-led unit, the SCCIU coordinates individual QCOR committees. The SCCIU supports administrative and mandatory reporting such as for financial incentive programs and departmental performance measures. The SCCIU is also responsible for the development and maintenance of registry applications. This QCOR 2017 Annual Report includes two new clinical audits, cardiac rehabilitation and electrophysiology and pacing, with a total of five audits encompassing cardiology and cardiothoracic surgery. With continued development, QCOR aims to support improved health care and outcomes of cardiac patients across Queensland.

Tier 1: Director General

Tier 2: Deputy Director General Clinical Excellence Division

Tier 3: Executive Director Healthcare Improvement Unit

Tier 4: Steering Committee Statewide Cardiac Clinical Network

QCOR Business Unit QCOR SCCIU Advisory Committee

QCOR QCOR QCOR QCOR QCOR QCOR Interventional Electrophysiology Cardiac Heart Failure Cardiothoracic Cardiac Imaging Cardiology and Pacing Rehabilitation Committee Surgery Committee Committee Committee Committee Committee

Figure A: Operational structure

Page 2 QCOR Annual Report 2017 4848877 20 11 40 Queensland population 20161 Australias total population1 Hospital spending on Aboriginal and Torres Strait cardiovascular disease2 Islander population3

23 11 31 29 of Queenslanders have of Queenslanders of Queenslanders have of deaths in Queenslanders caused untreated high blood pressure2 smoke daily2 untreated high total cholesterol2 by cardiovascular disease2

4928 3134 390 2364 percutaneous coronary electrophysiology and structural heart disease adult cardiac surgeries interventions pacing procedures4 interventions

4528 6368 91 85 new heart failure support cardiac rehabilitation of patients referred to a heart of cardiac rehabilitation services referrals referrals4 failure support service on assessments within 28 days an ACEI or AR at discharge of discharge

46 mins 86 mins 51 mins 11 median door to balloon median first diagnostic ECG to median pre-hospital mortality rate for coronary time for primary PCI reperfusion time for primary PCI component for primary PCI artery bypass surgery

Figure B: QCOR 2017 infographic

QCOR Annual Report 2017 Page 3 3 Executive summary

• 15,293 diagnostic or interventional cases were performed across the 8 cardiac catheterisation laboratory facilities in Queensland public hospitals. Of these, 4,928 were percutaneous coronary intervention (PCI). • The median age of Aboriginal and Torres Strait Islander patients undergoing PCI is 11 years younger than non- Aboriginal and Torres Strait Islander patients. • 75% of all PCI patients residing in Queensland had a place of residence within 50km of the nearest PCI capable facility. 12% of patients reside more than 150km from the nearest facility. • Mortality within 30 days following PCI was 1.9%. Of these 91 deaths, 80% were classed as either salvage or emergency PCI. • Statewide, a 7-minute improvement in median reperfusion time was observed compared to 2016 PCI analysis. • Observed rates for cardiac surgery mortality and most results for major morbidities are better than risk scores predict. • Additions to the cardiac surgery database will allow for calculation of EuroSCORE II, aetiology and microbiology of infective endocarditis, prehospital use of Statins and Anti-hypertensive agents. • Large proportions of patients have combinations of risk factors, for example obesity and diabetes, smoking and hypertension; emphasising the need for public health programs and primary care for cardiac surgery. • The reoperation rate for coronary artery bypass graft surgery and deep sternal wound infection in 2017 will be reviewed in detail in the 2018 QCOR annual report. • 74% of cardiac surgery patients are overweight or obese, including morbid obesity. This will be the focus of the supplement in the next report. • Seven sites contributed electrophysiology and pacing data with staggered commencement dates for these data collections. • 3,134 electrophysiology and pacing cases were performed across the 7 participating public Queensland sites. • 2,131 device procedures and 889 electrophysiology procedures were performed with 114 procedures classed as other. • The statewide aggregate for all device procedure complications was 4.6%, while all electrophysiology procedures had a 2.6% complication rate overall. • 6,368 cardiac rehabilitation referrals were made to participating programs in the July–December 2017 period. • The proportion of Aboriginal and Torres Strait Islander patients receiving a cardiac rehabilitation referral was 6.6%, with wide variation across the state. This population group was more vastly represented in north Queensland. • A timely cardiac rehabilitation referral (within three days of patient discharge) occurred in 94% of cases. • Of the timely referrals, a timely cardiac rehabilitation assessment (within 28 days of discharge) occurred in 85% of cases. • There were 4,528 new heart failure support service referrals in 2017 (13% increase from 2016). • Benchmarks were achieved for clinical indicators related to timely follow-up of referrals, assessment of left ventricular function, and prescription of angiotensin-converting-enzyme inhibitor or angiotensin II receptor blockers and appropriate beta blockers (bisoprolol, carvedilol, metoprolol sustained release, or nebivolol). • Beta blocker titration was below recommended benchmarks with only 34% achieving target doses and 70% achieving target or maximum tolerated dose within 6 months from referral. • Outcomes for the 2016 inpatient referrals highlights substantial disease burden with 14% dying and 58% rehospitalised within 12 months. • Days alive and out of hospital analysis reveals over 90,000 days lost due to death or hospitalisation in the 2,491 inpatient referral cohort over the following 12 months.

Page 4 QCOR Annual Report 2017 4 Acknowledgements and authors

This collaborative report was produced by the Statewide Cardiac Clinical Informatics Unit, audit lead for the Queensland Cardiac Outcomes Registry for and on behalf of the Statewide Cardiac Clinical Network. The work of the Queensland Cardiac Outcomes Registry would not be possible without the continued support and funding from the Clinical Excellence Division, Queensland Health. This publication draws on the expertise of many people. In particular, staff from the Statistical Services Branch the Healthcare Improvement Unit and the Queensland Ambulance Service within the Department of Health and Emergency Services each make significant contributions to ensure the success of the program. Furthermore, the tireless work of clinicians who contribute and collate quality data, as part of providing quality patient care, ensures credible analysis, and monitoring of the standard of cardiac services in Queensland.

Interventional Cardiology Cardiac Surgery Dr Tan Doan Dr Christopher Cole • Research Fellow, Information Support, Research and • Cardiothoracic Surgeon, Princess Alexandra Hospital Evaluation, Queensland Ambulance Service • Chair, QCOR Cardiothoracic Surgery Committee Dr Paul Garrahy Mr Marcus Prior • Director of Cardiology, Princess Alexandra Hospital • Principal Project Manager, Statewide Cardiac Clinical • Chair, Statewide Cardiac Clinical Network Informatics Unit Dr Christopher Hammett Dr Ian Smith • Interventional Cardiologist, Royal Brisbane and • Biostatistician, Statewide Cardiac Clinical Informatics Women’s Hospital Unit A/Prof Richard Lim Mr William Vollbon • Interventional Cardiologist, Princess Alexandra • Manager, Statewide Cardiac Clinical Informatics Unit Hospital Dr Rohan Poulter Electrophysiology and Pacing • Director of Cardiology, Sunshine Coast University Mr John Betts Hospital • Consultant Cardiac Physiologist, The Prince Charles Mr Marcus Prior Hospital • Principal Project Manager, Statewide Cardiac Clinical Mr Andrew Claughton Informatics Unit • Advanced Cardiac Physiologist, Princess Alexandra A/Prof Atifur Rahman Hospital • Interventional Cardiologist, Gold Coast University Dr Russell Denman Hospital • Director, Electrophysiology and Pacing, The Prince Mr Brett Rogers Charles Hospital • Statewide Reperfusion Coordinator, Queensland Ms Sanja Doneva Ambulance Service • Consultant Cardiac Physiologist, Princess Alexandra Mr Michael Savage Hospital • Consultant Cardiac Physiologist, The Prince Charles A/Prof John Hill Hospital • Director, Electrophysiology and Pacing, Princess Dr Ian Smith Alexandra Hospital • Biostatistician, Statewide Cardiac Clinical Informatics • Chair, QCOR Electrophysiology and Pacing Unit Committee Dr Gregory Starmer Dr Paul Martin • Director of Cardiology, Cairns Hospital • Electrophysiologist, Royal Brisbane and Women’s • Chair, QCOR Interventional Cardiology Committee Hospital Mr William Vollbon Mr Marcus Prior • Manager, Statewide Cardiac Clinical Informatics Unit • Principal Project Manager, Statewide Cardiac Clinical Informatics Unit Mr William Vollbon • Manager, Statewide Cardiac Clinical Informatics Unit

QCOR Annual Report 2017 Page 5 Cardiac Rehabilitation Heart Failure Support Services Mr Gary Bennett A/Prof John Atherton • Nurse Unit Manager, Chronic Disease, The COACH • Director of Cardiology, Royal Brisbane and Women’s Program, Health Contact Centre Hospital Dr Johanne Neill • Co-chair, QCOR Heart Failure Services Committee • Staff Specialist, Cardiology, Ipswich Hospital Ms Annabel Hickey Ms Kathy O’Donnell • Statewide Heart Failure Services Coordinator • Clinical Nurse Consultant, Heart Health and Cardiac Ms Tracey Nunan Rehabilitation Program, Gold Coast Hospital and • Nurse Practitioner, Sunshine Coast University Health Service Hospital Ms Samara Phillips • Co-chair, QCOR Heart Failure Services Committee • Project Manager, Statewide Cardiac Rehabilitation Ms Robyn Peters Project, Statewide Cardiac Clinical Network • Nurse Practitioner, Princess Alexandra Hospital Mr Marcus Prior Mr Marcus Prior • Principal Project Manager, Statewide Cardiac Clinical • Principal Project Manager, Statewide Cardiac Clinical Informatics Unit Informatics Unit Mr William Vollbon Mr William Vollbon • Manager, Statewide Cardiac Clinical Informatics Unit • Manager, Statewide Cardiac Clinical Informatics Unit Mr Stephen Woodruffe Dr Yee Weng Wong • Chair, QCOR Cardiac Rehabilitation Committee • Heart Failure and Cardiac Transplant Cardiologist, • Exercise Physiologist, Ipswich Cardiac Rehabilitation The Prince Charles Hospital Program

Page 6 QCOR Annual Report 2017 5 QCOR Committees

Interventional Cardiology Electrophysiology and Pacing Dr Christopher Hammett A/Prof Ravinder Batra • Interventional Cardiologist, Royal Brisbane and • Electrophysiologist, Gold Coast University Hospital Women’s Hospital Mr John Betts A/Prof Richard Lim • Consultant Cardiac Physiologist, The Prince Charles • Interventional Cardiologist, Princess Alexandra Hospital Hospital Mr Andrew Claughton Dr Rohan Poulter • Advanced Cardiac Physiologist, Princess Alexandra • Director of Cardiology, Sunshine Coast University Hospital Hospital Dr Russell Denman A/Prof Atifur Rahman • Director, Electrophysiology and Pacing, The Prince • Interventional Cardiologist, Gold Coast University Charles Hospital Hospital Ms Sanja Doneva Dr Niranjan Gaikwad • Consultant Cardiac Physiologist, Princess Alexandra • Interventional Cardiologist, The Prince Charles Hospital Hospital Ms Kellie Foder Dr Ryan Schrale • Advanced Cardiac Physiologist, Royal Brisbane and • Interventional Cardiologist, The Townsville Hospital Women’s Hospital Dr Gregory Starmer (Chair) A/Prof John Hill (Chair) • Director of Cardiology, Cairns Hospital • Director, Electrophysiology and Pacing, Princess Dr Michael Zhang Alexandra Hospital • Director of Cardiology, Mackay Base Hospital Dr Paul Martin • Electrophysiologist, Royal Brisbane and Women’s Cardiac Surgery Hospital Dr Robert Park Dr Christopher Cole (Chair) • Electrophysiologist, The Townsville Hospital • Cardiothoracic Surgeon, Princess Alexandra Hospital Ms Leanne Slater Dr Anand Iyer • Clinical Nurse Consultant EP, Princess Alexandra • Cardiothoracic Surgeon, The Townsville Hospital Hospital Dr Morgan Windsor Dr Steve Sutcliffe • Director of Thoracic Surgery, Royal Brisbane and • Cardiologist, Cairns Hospital Women’s Hospital and The Prince Charles Hospital Dr Anil Prabhu • Cardiothoracic Surgeon, The Prince Charles Hospital Dr Andrie Stroebel • Cardiothoracic Surgeon, Gold Coast University Hospital

QCOR Annual Report 2017 Page 7 Cardiac Rehabilitation Heart Failure Support Services Mr Godfrey Martis Ajgaonkar Ms Julie Adsett • Nurse Practitioner (Cardiac), Mt Isa Hospital • Physiotherapist, Royal Brisbane and Women’s Mr Gary Bennett Hospital • Nurse Unit Manager, Chronic Disease, The COACH Mr Godfrey Martis Program, Health Contact Centre • Nurse Practitioner (Cardiac), Mt Isa Hospital Ms Jacqueline Cairns A/Prof John Atherton (Co-chair) • Cardiac Rehabilitation Coordinator, Cairns Hospital • Director of Cardiology, Royal Brisbane and Women’s Ms Yvonne Martin Hospital • Clinical Nurse Consultant, Chronic Disease Brisbane A/Prof Charles Denaro South • Director of Internal Medicine and Aged Care, Royal Dr Johanne Neill Brisbane and Women’s Hospital • Staff Specialist, Cardiology, Ipswich Hospital Ms Tina Ha Ms Samara Phillips • Pharmacist, Princess Alexandra Hospital • Project Manager, Statewide Cardiac Rehabilitation Ms Annabel Hickey Project, Statewide Cardiac Clinical Network • Statewide Heart Failure Services Coordinator, The Mr Ben Shea Prince Charles Hospital • A/Clinical Nurse Consultant, Princess Alexandra Dr George Javorsky Hospital • Clinical Director, Advanced Heart Failure and Cardiac Ms Deborah Snow Transplant Unit, The Prince Charles Hospital • Clinical Nurse Consultant, Heart Health and Cardiac Dr Dariusz Korczyk Rehabilitation Program, Gold Coast Hospital and • Cardiologist, Princess Alexandra Hospital Health Service Dr Louise McCormack Ms Marie Steer • Cardiologist, Royal Brisbane & Women’s Hospital • Physiotherapist, Complex Chronic Disease Team, Ms Emma McGlynn Metro North Hospital and Health Service • Clinical Nurse Consultant, Princess Alexandra Mr Stephen Woodruffe (Chair) Hospital • Exercise Physiologist, Ipswich Cardiac Rehabilitation Ms Kellie Mikkelsen Program • A/Clinical Nurse Consultant, Heart Failure Service, The Prince Charles Hospital Ms Tracey Nunan (Co-chair) • Nurse Practitioner (Cardiology), Sunshine Coast University Hospital Ms Robyn Peters • Nurse Practitioner (Cardiology), Princess Alexandra Hospital Ms Serena Rofail • Pharmacist, Royal Brisbane and Women’s Hospital Ms Menaka Sabaratnam • Physiotherapist, Gold Coast University Hospital Ms Angie Sutcliffe • Nurse Practitioner (Heart failure), Cairns Hospital Dr Steve Sutcliffe • Cardiologist, Cairns Hospital Ms Karen Uhlmann • Acute Sector Manager, Heart Foundation Representative Dr Yee Weng Wong • Cardiologist, The Prince Charles Hospital

Page 8 QCOR Annual Report 2017 6 Future plans

The QCOR report has expanded this year to include two new modules for statewide cardiac rehabilitation and electrophysiology and pacing services. The continued growth and success of the registry can be largely credited to the commitment of participating cardiac clinical staff across the state. This work has presented new opportunities for more sophisticated reporting and analyses. Over the next year, the focus will remain on delivering enhanced and innovative information solutions to support Queensland clinicians in delivering world-class patient care. • Through increasing insight into the care provided to Queensland cardiac patients across participating domains, more complete analyses regarding outcomes for patients attending across multiple cardiac services are now feasible. In reports to come, allowing more complete results to provide more complete insights into the quality of care provided to our cardiac patients as they journey between various clinical specialty groups. Areas which have been highlighted as a focus for future reports include outcomes for patients that have undergone percutaneous coronary intervention and then subsequent cardiac surgery and the inter-relationship between interventional and outpatient services. • A new QCOR Structural Heart Disease module is currently being developed with deployment expected in early 2019. This QCOR module has been developed to provide superior procedure reporting capabilities for structural heart disease interventions, device closure, and percutaneous valve replacement and repair procedures, and will enable future statewide participation in national quality and safety activities for transcatheter aortic valve replacement. • The Annual Cardiac Surgery Audit continues to identify future enhancement opportunities. This is highlighted by this year’s supplementary report on infective endocarditis surgical interventions, which recommends adding detail about the microbiology and aetiology of endocarditis infection to the registry. Given the tremendous impact and associated healthcare costs for patients undergoing repeat valve surgery due to prosthetic valve endocarditis, these additions are clearly warranted. These improvements as well as data fields allowing EuroSCORE II Risk Adjustment will be delivered in late 2018. • In 2017/18 the QCOR provided data and reporting for the of the State Government funded Quality Incentive Payment for performance in cardiac rehabilitation. The registry will continue to build upon the excellent levels of clinician engagement to deliver a contemporary and evidence-based clinical indicator program to support quality improvement activities in this field. New system capabilities will be deployed over the next few months to allow more comprehensive assessment of patient activity and exercise levels and assist clinicians to perform everyday tasks and patient care. • Electrophysiology and pacing services across Queensland have participated in their first QCOR review. This follows the delivery of a bespoke reporting application by the Statewide Cardiac Clinical Network’s Cardiac Information Solutions Program. The project has seen a staggered uptake of the new application throughout 2017 with the final site beginning direct entry in early 2018. This has resulted in an unprecedented availability of data across services where reporting had been predominately paper-based. The report has identified several areas for improved data quality, while another focus will be to collaborate with electrophysiology and pacing clinicians to deliver a future clinical indicator program. • Heart failure support services across Queensland have now been contributing to the QCOR quality registry since 2014. Over time, the growth of the registry has allowed more sophisticated analyses to be undertaken. This is highlighted by this year’s reporting of statewide heart failure patient outcomes, which identified several priority areas for further development of the registry. Additional data points relating to mineralocorticoid receptor antagonists will be added to the data collection in late 2018, while an early investigation and scoping of a potentially new and expanded QCOR heart failure application is also underway. • Contributions from the Queensland Ambulance Service (QAS) have been integral to the composition of this report. Collaboration between Queensland Health and QAS has been bolstered with continued investment by both organisations into cardiac outcomes. The future of this partnership is promising with a shared goal of improving patient outcomes and pre-hospital processes for Queenslanders suffering cardiovascular disease.

QCOR Annual Report 2017 Page 9 Page 10 QCOR Annual Report 2017 Interventional Cardiology Audit Interventional Cardiology Interventional

QCOR Annual Report 2017 Page IC 1 Interventional Cardiology Interventional

Page IC 2 QCOR Annual Report 2017 7 Message from the QCOR Interventional Cardiology Committee Chair

The third Annual Report of interventional cardiology activity in Queensland sees further expansion and maturation of this clinical registry and, perhaps more importantly, it has become a component of the much broader analysis of cardiac service provision in Queensland. The interventional cardiology services analysed now include procedures performed at all 8 public cardiology catheter labs in Queensland, encompassing

4 metropolitan sites, and 4 regional sites. The geographical challenges associated with delivering tertiary Cardiology Interventional cardiac care are highlighted in this year’s report, with one in four people having to travel more than 50km to a cardiac catheter lab. The report also confirms the health “gap” attributable to cardiovascular disease between Indigenous and non-Indigenous Queenslanders, with the median age of Indigenous patients undergoing percutaneous coronary intervention observed to be 11 years younger than non-Indigenous patients. One of the aims of this registry is to provide meaningful, quality information to facilitate improvements in systems, care and ultimately, outcomes, and it is therefore pleasing to also observe that there has been a year-on-year improvement in the important metric of “time to open artery” for people having an acute heart attack. With the ongoing evolution of the Queensland Cardiac Outcomes Registry, the compilation and analysis of this ever-increasing volume of data is a significant undertaking, and I would certainly like to express my gratitude to the entire QCOR team, who are committed to quality improvement in cardiac care for all Queenslanders.

Dr Greg Starmer Chair QCOR Interventional Cardiology Committee

QCOR Annual Report 2017 Page IC 3 8 Key findings

This third audit describes key aspects of the care and treatment of cardiac patients receiving percutaneous coronary interventions (PCI) during 2017. Key findings include: • 15,293 diagnostic or interventional cases were performed across the 8 cardiac catheterisation laboratory facilities in Queensland public hospitals. Of these, 4,928 were PCI.

Interventional Cardiology Interventional • The proportion of patients identified as Aboriginal andTorres Strait Islander again illustrates a stepwise gradient based on geographical area with the highest proportions found in the north of the state and the lowest in the South East corner. This is consistent with previous analyses. • The median age of Aboriginal and Torres Strait Islander patients undergoing PCI was 11 years younger than non-Aboriginal and Torres Strait Islander patients. • A large proportion of PCI patients (77%) were classed as having an unhealthy body mass index over 25kg/ m2. • 75% of all PCI patients residing in Queensland had a place of residence within 50km of the nearest PCI capable facility, while 12% of patients resided more than 150km from the nearest facility. • The majority of PCI cases (76%) were classed as urgent, emergent or salvage, highlighting the acute and often unstable patient cohort. • Drug eluting stents (DES) were used in 85% of cases with a range between 63% and 98% across sites. • PCI for non-ST elevation myocardial infarction (NSTEMI) represented 29% of all cases, with the median time to angiography of 53 hours. Patients presenting to a non-PCI capable facility have a median wait to coronary angiography 31 hours longer than those who present directly to a PCI capable facility (68 hours vs 37 hours). • There were 1,434 PCI cases following presentation with ST elevation myocardial infarction (STEMI) in 2017, of which 56% were managed by primary PCI. • Median time to reperfusion from first diagnostic ECG for STEMI patients presenting within 6 hours of symptom onset was 86 minutes (range 70 minutes to 98 minutes across sites). Statewide, a 7 minute improvement in median reperfusion time was observed compared to 2016. • Median hospital door to device time for STEMI patients presenting within six hours of symptom onset was 46 minutes (range 34 minutes to 60 minutes across sites). There was a 5 minute improvement in median door to device time compared to 2016 analyses. • Mortality within 30 days following PCI was 1.9%. Of these 91 deaths, 80% were classed as either salvage or emergency PCI. • Of all cases, 0.49% recorded a major intra-procedural complication. Coronary artery perforation accounted for the majority (0.37%) of these events. • Radiation doses were found to be under the high dose threshold in 97.9% of PCI cases across all sites and 99.9% of other coronary procedures.

Page IC 4 QCOR Annual Report 2017 Interventional Cardiology Audit

9 Participating sites

During 2017, there were 8 public hospitals offering cardiac catheter laboratory (CCL) services across both metropolitan and regional Queensland. This includes the Sunshine Coast University Hospital (SCUH) which opened in March 2017, with invasive cardiology services moving from Nambour General Hospital (NGH). Cases for NGH for the earlier part of the year are included under SCUH.

Table 1: Participating sites Interventional Cardiology Interventional Site number Site name Acronym 1 Cairns Hospital CH 2 The Townsville Hospital TTH 3 Mackay Base Hospital MBH 4 Sunshine Coast University Hospital SCUH 5 The Prince Charles Hospital TPCH 6 Royal Brisbane and Women’s Hospital RBWH 7 Princess Alexandra Hospital PAH 8 Gold Coast University Hospital GCUH

QCOR Annual Report 2017 Page IC 5 9.1 Statewide Patients came from a wide geographical area with the majority of patients residing on the Eastern Seaboard. More than half of all patients were seen at their local Hospital and Health Service (HHS) except for Royal Brisbane and Women’s Hospital, who treated 53% patients from outside their HHS boundary. Total cases included 65 patients from overseas, accounting for 1.3% of all PCI cases across all sites. Interventional Cardiology Interventional

Figure 1: PCI cases by residential postcode

Table 2: Proportion of cases with patient residential postcode within the treating HHS boundaries

Site Within HHS (%) Cairns Hospital 80.2 The Townsville Hospital 73.0 Mackay Base Hospital 93.8 Sunshine Coast University Hospital 76.1 The Prince Charles Hospital 62.6 Royal Brisbane and Women’s Hospital 47.3 Princess Alexandra Hospital 60.3 Gold Coast University Hospital 73.9

Page IC 6 QCOR Annual Report 2017 • Referral hospital for Cairns 9.2 Cairns Hospital and Hinterland and Torres and Cape Hospital and Health Services, serving a population of approximately 280,000 • Public tertiary level cardiac services provided at Cairns Hospital include: • Coronary angiography Interventional Cardiology Interventional • Percutaneous coronary intervention • Structural heart disease intervention • Pacemaker implantations • One cardiac catheter laboratory with a dedicated service commencing in 2010 • 24/7 PCI service available since April 2015 • 5.4 FTE consultant cardiologists.

Figure 2: Cairns Hospital

• Referral hospital for Townsville 9.3 The Townsville Hospital and North West Hospital and Health Services, serving a population of approximately 295,000 • Public tertiary level cardiac services provided at The Townsville Hospital include: • Coronary angiography • Percutaneous coronary intervention • Structural heart disease intervention • Electrophysiology • ICD, CRT and pacemaker implantation • Cardiac surgery • Two cardiac catheter laboratories with a dedicated service commencing in 1994 • 24/7 PCI service available since March 2016

Figure 3: The Townsville Hospital • 7.1 FTE consultant cardiologists

QCOR Annual Report 2017 Page IC 7 • Referral hospital for Mackay 9.4 Mackay Base Hospital and Whitsunday regions, serving a population of approximately 182,000 • Public tertiary level cardiac services provided at Mackay Base Hospital include: • Coronary angiography • Percutaneous coronary Interventional Cardiology Interventional intervention • ICD and pacemaker implantation • One cardiac catheter laboratory with a dedicated service commencing in 2014 • 4.6 FTE consultant cardiologists

Figure 4: Mackay Base Hospital

• Referral hospital for Sunshine 9.5 Sunshine Coast University Hospital Coast and Wide Bay Hospital and Health Services, serving a population of approximately 563,000 • Public tertiary level cardiac services provided at SCUH include: • Coronary angiography • Percutaneous coronary intervention • Structural heart disease intervention • Electrophysiology • ICD, CRT and pacemaker implantation • Three cardiac catheter laboratories with a dedicated service commencing in 2017 • 24/7 PCI service available since March 2017. Replaces NGH • 9.1 FTE consultant cardiologists

Figure 5: Sunshine Coast University Hospital

Page IC 8 QCOR Annual Report 2017 • Referral hospital for Metro 9.6 The Prince Charles Hospital North, Wide Bay and Central Queensland Hospital and Health Services, serving a population of approximately 900,000 (shared referral base with the Royal Brisbane and Women’s Hospital) • Public tertiary level cardiac services provided at TPCH include: • Coronary angiography Cardiology Interventional • Percutaneous coronary intervention • Structural heart disease intervention • Electrophysiology • ICD, CRT and pacemaker implantation • Cardiac surgery • Heart / lung transplant unit • Adult congenital heart disease clinic • Three cardiac catheter laboratories and one hybrid theatre. 24/7 PCI service available since 1995 Figure 6: The Prince Charles Hospital • 19.89 FTE consultant cardiologists

• Referral hospital for Metro 9.7 Royal Brisbane and Women’s Hospital North, Wide Bay and Central Queensland Hospital and Health Services, serving a population of approximately 900,000 (shared referral base with the Prince Charles Hospital) • Public tertiary level cardiac services provided at The Royal Brisbane and Women’s Hospital include: • Coronary angiography • Percutaneous coronary intervention • Structural heart disease intervention • Electrophysiology • ICD, CRT and pacemaker implantation • Two cardiac catheter laboratories with a dedicated service commencing in 1997

Figure 7: Royal Brisbane and Women’s Hospital • 24/7 PCI service available since 1997 • 11 FTE consultant cardiologists QCOR Annual Report 2017 Page IC 9 • Referral hospital for Metro 9.8 Princess Alexandra Hospital South and South West Hospital and Health Services, serving a population of approximately 1,000,000 • Public tertiary level cardiac services provided at the Princess Alexandra Hospital include:

Interventional Cardiology Interventional • Coronary angiography • Percutaneous coronary intervention • Structural heart disease intervention • Electrophysiology • ICD, CRT and pacemaker implantation • Cardiac surgery • Three cardiac catheter laboratories with a dedicated service commencing in 1998 • 24/7 PCI service available since November 1998 Figure 8: Princess Alexandra Hospital • 11.5 FTE consultant cardiologists

• Referral Hospital for Gold Coast 9.9 Gold Coast University Hospital and northern New South Wales regions, serving a population of approximately 700,000 • Public tertiary level cardiac services provided at the Gold Coast University Hospital include: • Coronary angiography • Percutaneous coronary intervention • Structural heart disease intervention • Electrophysiology • ICD, CRT and pacemaker implantation • Cardiac surgery • 24/7 PCI service available since 2006 • 8.25 FTE consultant cardiologists

Figure 9: Gold Coast University Hospital

Page IC 10 QCOR Annual Report 2017 10 Total cases

10.1 Procedure type In 2017, there were a total of 15,293 coronary cases which were performed across the 8 participating public cardiac catheter laboratories. Of the total cases, 4,928 (32%) involved percutaneous coronary interventions (PCI), with these cases the main subject of this report. Additional detail for 390 structural heart disease (SHD) cases have been included Cardiology Interventional as a supplement to this report.

Table 3: Total number of cases by procedure category

Site PCI procedure* Other coronary procedure† All cases n (%) n (%) n (%) CH 501 (34.9) 934 (65.1) 1,435 (100.0) TTH 398 (29.2) 965 (70.8) 1,363 (100.0) MBH 258 (26.7) 708 (73.3) 966 (100.0) SCUH 592 (39.9) 891 (60.1) 1,483 (100.0) TPCH 1,066 (27.2) 2,847 (72.8) 3,913 (100.0) RBWH 425 (32.0) 904 (68.0) 1,329 (100.0) PAH 1,004 (35.2) 1,847 (64.8) 2,851 (100.0) GCUH 684 (35.0) 1,269 (65.0) 1,953 (100.0) STATEWIDE 4,928 (32.2) 10,365 (67.8) 15,293 (100.0) * Includes POBA, coronary stenting, PTCRA/atherectomy and thrombectomy of coronary arteries † Includes coronary angiography, aortogram, coronary artery bypass graft study, left ventriculography, left heart catheterisation, coronary fistula embolisation, fractional flow reserve, intravascular ultrasound, optical coherence tomography and instantaneous wave free ratio

QCOR Annual Report 2017 Page IC 11 10.2 Total cases by diagnosis The most common diagnosis across all cases was of an acute coronary syndrome (ACS), which accounted for approximately one third of all cases (33%), and almost two thirds of all PCI cases (61%). The most common diagnosis was of Non-ST Elevation ACS (including both NSTEMI and unstable angina) while ST-Elevation ACS cases represented 11% of all cases, and 29% of all PCI cases.

Table 4: Total cases by diagnosis category

Interventional Cardiology Interventional Site STEMI NSTEMI Unstable angina No ACS All cases n (%) n (%) n (%) n (%) n (%) CH 166 (11.6) 307 (21.4) 16 (1.1) 946 (65.9) 1,435 (100.0) TTH 117 (8.6) 249 (18.3) 34 (2.5) 963 (70.7) 1,363 (100.0) MBH 49 (5.1) 127 (13.1) 77 (8.0) 713 (73.8) 966 (100.0) SCUH 266 (17.9) 331 (22.3) 32 (2.2) 854 (57.6) 1,483 (100.0) TPCH 279 (7.1) 665 (17.0) 28 (0.7) 2,941 (75.2) 3,913 (100.0) RBWH 123 (9.3) 363 (27.3) 26 (2.0) 817 (61.5) 1,329 (100.0) PAH 494 (17.3) 678 (23.8) 121 (4.2) 1,558 (54.6) 2,851 (100.0) GCUH 225 (11.5) 283 (14.5) 30 (1.5) 1,415 (72.5) 1,953 (100.0) STATEWIDE 1,719 (11.2) 3,003 (19.6) 364 (2.4) 10,207 (66.7) 15,293 (100.0)

Table 5: PCI cases by diagnosis category

Site STEMI NSTEMI Unstable angina No ACS All PCI cases n (%) n (%) n (%) n (%) n (%) CH 139 (27.7) 164 (32.7) 11 (2.2) 187 (37.3) 501 (100.0) TTH 104 (26.1) 78 (19.6) 12 (3.0) 204 (51.3) 398 (100.0) MBH 35 (13.6) 61 (23.6) 22 (8.5) 140 (54.3) 258 (100.0) SCUH 232 (39.2) 149 (25.2) 11 (1.9) 200 (33.8) 592 (100.0) TPCH 241 (22.6) 309 (29.0) 5 (0.5) 511 (47.9) 1,066 (100.0) RBWH 95 (22.4) 174 (40.9) 16 (3.8) 140 (32.9) 425 (100.0) PAH 388 (38.6) 312 (31.1) 55 (5.5) 249 (24.8) 1,004 (100.0) GCUH 200 (29.2) 160 (23.4) 12 (1.8) 312 (45.6) 684 (100.0) STATEWIDE 1,434 (29.1) 1,407 (28.6) 144 (2.9) 1,943 (39.4) 4,928 (100.0)

Page IC 12 QCOR Annual Report 2017 11 Patient characteristics

11.1 Age and gender Age is an important risk factor for developing cardiovascular disease. The median age of patients undergoing PCI was 64 years of age and ranged from 61 years to 67 years across sites. The median age for females was higher than males (68 years vs. 63 years). Interventional Cardiology Interventional

Male Female

≥85

80-84

75-79

70-74

65-69

60-64

55-59

50-54

45-49

40-44

<40

15% 10% 5% 0% 0% 5% 10% 15%

% of total PCI (n=4,928) Figure 10: Proportion of all PCI cases by gender and age group

Table 6: Median age by gender for all PCI cases

Male Female All (years) (years) (years) CH 61.4 62.4 61.6 TTH 61.0 66.2 62.1 MBH 65.8 69.8 66.9 SCUH 65.8 68.0 66.3 TPCH 65.2 68.9 66.2 RBWH 61.4 68.8 62.9 PAH 60.0 65.7 61.3 GCUH 63.0 69.8 64.6 STATEWIDE 63.1 67.8 64.1

QCOR Annual Report 2017 Page IC 13 11.2 Body mass index Patients across all sites displayed similar results for body mass index (BMI), with less than one-quarter of patients (22%) in the normal BMI range and 38%, 34% and 5% classified as overweight, obese and morbidly obese respectively. There were 1% of cases classified as underweight. These analyses compare similarly with 2015 and 2016 data.

Normal weight* Overweight† Obese‡ Morbidly obese§

CH Interventional Cardiology Interventional

TTH

MBH

SCUH

TPCH

RBWH

PAH

GCUH

STATEWIDE

0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50%

* BMI 18.5–24.9 kg/m2

† BMI 25–29.9 kg/m2

‡ BMI 30–39.9 kg/m2

§ BMI ≥40 kg/m2 Figure 11: Proportion of all PCI cases by body mass index category

Page IC 14 QCOR Annual Report 2017 11.3 Place of residence The majority (93%) of patients were recorded as having their usual place of residence within Queensland. This was similar across all sites with the exception of the Gold Coast University Hospital where 23% of PCI patients originated from outside of Queensland. Of those patients residing in Queensland, the majority (75%) had a place of usual residence which was within 50 kilometres of the nearest PCI facility.

Table 7: PCI cases by place of usual residence Interventional Cardiology Interventional Site Queensland Interstate Overseas (%) (%) (%) CH 95.4 2.6 2.0 TTH 97.0 2.0 1.0 MBH 96.9 2.3 0.8 SCUH 94.9 3.2 1.9 TPCH 95.1 4.2 0.7 RBWH 95.7 2.8 1.4 PAH 97.3 1.4 1.3 GCUH 77.5 20.7 1.8 STATEWIDE 93.4 5.3 1.3

Table 8: Queensland PCI cases by distance from place of residence to nearest PCI facility

Site <50 km 50–150 km >150 km (%) (%) (%) CH 62.6 25.0 12.5 TTH 61.2 21.9 16.9 MBH 72.0 20.4 7.6 SCUH 76.1 17.0 7.0 TPCH 75.5 7.6 16.9 RBWH 64.2 10.6 25.2 PAH 79.2 13.8 7.0 GCUH 98.7 0.6 0.8 STATEWIDE 75.3 13.2 11.5

QCOR Annual Report 2017 Page IC 15 Interventional Cardiology Interventional

Figure 12: Queensland PCI cases by distance to nearest PCI facility

Page IC 16 QCOR Annual Report 2017 11.4 Aboriginal and Torres Strait Islander status Ethnicity is an important determinant of health with a particular impact on the development of cardiovascular disease. It is recognised that the Aboriginal and Torres Strait Islander population have a higher incidence and prevalence of coronary artery disease. The increased proportion of identified Aboriginal and Torres Strait Islander patients in the northern HHSs (CH, 23.6% and TTH, 15.6%) reflects the resident population within these areas and should be noted for future service provision and planning.

The proportion of identified Aboriginal and Torres Strait Islander patients requiring a PCI procedure across Cardiology Interventional all sites (6.3%) exceeds the estimated proportion of Aboriginal and Torres Strait Islander persons within Queensland (4.0%).3

CH

TTH

MBH

SCUH

TPCH

RBWH

PAH

GCUH

STATEWIDE

0% 5% 10% 15% 20% 25%

Figure 13: Proportion of all PCI cases by identified Aboriginal and Torres Strait Islander status

QCOR Annual Report 2017 Page IC 17 The median age of Aboriginal and Torres Strait Islander patients undergoing PCI was lower than that of non- Aboriginal and Torres Strait Islander patients (54 years vs 65 years).

Male Female

≥85

80-84

75-79

Interventional Cardiology Interventional 70-74

65-69

60-64

55-59

50-54

45-49

40-44

<40

15% 10% 5% 0% 0% 5% 10% 15%

Legend Indigenous male Indigenous female Non-Indigenous

% of total PCI cases (n=4,928) Figure 14: Proportion of all PCI cases by age group and Aboriginal and Torres Strait Islander status

Table 9: PCI cases median patient age by gender and Aboriginal and Torres Strait Islander status

Total cases Male Female All (n) (years) (years) (years) Aboriginal and Torres Strait Islander 311 51.8 56.0 53.7 Non Aboriginal and Torres Strait Islander 4,617 63.6 68.5 64.7 ALL 4,928 63.1 67.8 64.1

Page IC 18 QCOR Annual Report 2017 12 Care and treatment of PCI patients

12.1 Admission status A total of 4,928 PCI procedures were performed in 2017 by the 8 contributing cardiology centres across Queensland. Patients were classified into admission status defined by the National Cardiovascular Data Registry as follows:4 Interventional Cardiology Interventional Despite published definitions, the percentage distribution varied considerably between institutions as classification of cases is sometimes operator-dependent.

Table 10: Diagnostic coronary angiography status

Status Definition Elective The procedure can be performed on an outpatient basis or during a subsequent hospitalisation without significant risk of infarction or death. For stable inpatients, the procedure is being performed during this hospitalisation for convenience and ease of scheduling and not because the patient’s clinical situation demands the procedure prior to discharge. Urgent* The procedure is being performed on an inpatient basis and prior to discharge because of significant concerns that there is risk of ischaemia, infarction and/or death. Patients who are outpatients or in the emergency department at the time the cardiac catheterisation is requested would warrant an admission based on their clinical presentation. Emergency† The procedure is being performed as soon as possible because of substantial concerns that ongoing ischaemia and/or infarction could lead to death. “As soon as possible” refers to a patient who is of sufficient acuity that you would cancel a scheduled case to perform this procedure immediately in the next available room during business hours, or you would activate the on call team were this to occur during off-hours. Salvage‡ The procedure is a last resort. The patient is in cardiogenic shock at the start of the procedure. Within the last ten minutes prior to the start of the procedure the patient has also received chest compressions for a total of at least sixty seconds or has been on unanticipated extracorporeal circulatory support (e.g. extracorporeal membrane oxygenation, cardiopulmonary support) * Typically includes NSTEMI † Typically includes STEMI ‡ Haemodynamically unstable

QCOR Annual Report 2017 Page IC 19 The majority (76%) of PCI cases were classed as urgent, emergent or salvage PCI. This reflects the acute and often complex case mix draining to Queensland public hospitals. Salvage cases varied between institutions with CH and RBWH performing almost 3% of their PCI cases in these complex clinical scenarios.

Elective

Urgent

Interventional Cardiology Interventional Emergency

Salvage

0% 10% 20% 30% 40% 50% 60%

Figure 15: Proportion of all PCI cases by admission status

Table 11: PCI cases by site and admission status

Total cases Elective Urgent Emergent Salvage (n) (%) (%) (%) (%) CH 501 23.4 52.5 21.4 2.8 TTH 398 18.3 62.6 18.3 0.8 MBH 258 44.6 50.8 4.7 0.0 SCUH 592 17.4 50.5 31.8 0.3 TPCH 1,066 33.1 47.0 19.6 0.3 RBWH 425 15.8 61.9 19.5 2.8 PAH 1,004 19.9 53.9 25.8 0.4 GCUH 684 24.6 46.2 28.1 1.2 STATEWIDE 4,928 24.3 52.0 22.8 0.9

Page IC 20 QCOR Annual Report 2017 12.2 Access route Across all sites, the majority of PCI cases (92%) used a single access route, with 57% being via the radial approach, 34% femoral, and less than one per cent via another access route including brachial or ulnar. The use of the radial approach varied between different PCI centres (23% to 80%). Multiple access routes were recorded for 8% of cases. This includes the use of a dual approach (both radial and femoral) as well as unsuccessful approaches with subsequent crossover to another access route.

Table 12: PCI access route by site Cardiology Interventional

Radial Femoral Other Multiple approaches (%) (%) (%) (%) CH 74.9 16.6 - 8.6 TTH 49.5 46.5 0.8 3.3 MBH 63.8 27.2 - 9.1 SCUH 79.6 13.2 0.5 6.8 TPCH 58.3 27.0 0.1 14.6 RBWH 65.2 25.2 0.2 9.4 PAH 23.3 73.1 - 3.6 GCUH 70.3 20.9 - 8.8 STATEWIDE 57.2 34.3 0.2 8.3

QCOR Annual Report 2017 Page IC 21 12.3 Vessels treated Of all vessels or grafts treated by PCI, the majority were native vessels. Of the native vessels treated, 45% involved the left anterior descending coronary artery (LAD), followed by the right coronary artery (RCA) at 37%, the circumflex coronary artery (LCx) at 23% and the left main coronary artery (LMCA) at less than three per cent. Coronary artery graft PCI accounted for 3% of case volume.

Table 13: Vessels treated by site

LAD LMCA LCx RCA GRAFT Interventional Cardiology Interventional (%) (%) (%) (%) (%) CH 43.3 2.6 23.2 35.7 2.2 TTH 44.0 3.6 21.2 31.9 4.1 MBH 41.7 0.4 25.5 33.2 2.4 SCUH 44.3 2.9 23.8 38.0 3.7 TPCH 44.6 4.2 24.0 38.7 3.4 RBWH 45.8 1.2 22.4 41.0 2.8 PAH 46.3 1.5 19.4 36.1 3.4 GCUH 43.6 1.5 23.4 36.8 1.9 STATEWIDE 44.5 2.5 22.6 36.9 3.1

Page IC 22 QCOR Annual Report 2017 12.4 Stent type Stents are grouped into one of four different types – drug-eluting stents (DES), bare metal stents (BMS), bioresorbable vascular scaffolds (BVS) and covered stents. Across all centres, an average of 1.5 stents were used for each of the 4,642 PCI cases involving stent deployment. Drug eluting stents were used in 85% of cases, ranging 73% to 98% across centres, while BMS were used in 15% of cases. A BVS or covered stent was used in less than 1% of cases.

DES BMS Interventional Cardiology Interventional CH

TTH

MBH

SCUH

TPCH

RBWH

PAH

GCUH

STATEWIDE

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%

Figure 16: Proportion of cases including at least one stent by site and stent type

Table 14: PCI cases including at least one stent deployed by site and stent type

Total DES BMS BVS Covered stent Stents per case (n) (%) (%) (%) (%) (mean) CH 458 89.5 6.3 5.0 0.0 1.5 TTH 381 95.8 4.5 0.0 0.5 1.5 MBH 226 95.6 4.4 0.0 0.4 1.4 SCUH 564 86.9 14.0 0.0 0.7 1.5 TPCH 996 98.1 1.5 0.3 0.1 1.6 RBWH 408 95.8 5.6 0.0 0.5 1.7 PAH 976 73.2 29.5 0.0 0.2 1.5 GCUH 633 62.6 39.0 0.0 0.0 1.4 STATEWIDE 4,642 85.3 15.2 0.6 0.3 1.5

QCOR Annual Report 2017 Page IC 23 12.5 NSTEMI

12.5.1 Case load Of all PCI and coronary cases performed in cardiac catheter suites during 2017, there were 3,003 (20%) which were coded with a procedural indication of NSTEMI. NSTEMI cases accounted for 29% of PCI cases across all centres, with site variation ranging from 23% to 41%. Interventional Cardiology Interventional Table 15: NSTEMI cases

Site Total NSTEMI cases NSTEMI receiving PCI Proportion of all PCI cases (n) n (%) (%) CH 307 164 (53.4) 32.7 TTH 249 78 (31.3) 19.6 MBH 127 61 (46.0) 23.6 SCUH 331 149 (45.0) 25.2 TPCH 665 309 (46.5) 29.0 RBWH 363 174 (47.9) 40.9 PAH 678 312 (46.0) 31.1 GCUH 283 160 (56.5) 23.4 STATEWIDE 3,003 1,407 (46.8) 28.6

12.5.2 Admission source Overall there were more NSTEMI cases where the patient was transferred from another facility than those presenting directly to the PCI capable facility (54% and 46% respectively). Considerable variation was observed between participating sites, with the proportion of interhospital transfers for NSTEMI ranging from 41% to 70%.

Table 16: NSTEMI admission source to treating facility

Site NSTEMI cases Direct to treating facility Interhospital transfer (n) (%) (%) CH 307 59.3 40.7 TTH 249 59.4 40.6 MBH 127 54.3 45.7 SCUH 331 52.0 48.0 TPCH 665 51.1 48.9 RBWH 363 32.8 67.2 PAH 678 30.4 69.6 GCUH 283 49.8 50.2 STATEWIDE 3,003 45.8 54.2

Page IC 24 QCOR Annual Report 2017 12.5.3 Hospital performance – Time to angiography Time to coronary angiography for patients presenting to hospital with a NSTEMI continues to be a key clinical quality indicator for QCOR. National and international guidelines remain unchanged since the 2015 report with recommendations stating coronary angiography should be offered and performed within 72 hours of diagnosis.5 A major barrier often cited in achieving this target is the time taken to transfer patients from non-PCI capable facilities to the accepting facility. There are multiple reasons delays can occur including capacity constraints and transfer logistics. The overall outcome of this indicator is presented later. Interventional Cardiology Interventional Compared with patients presenting directly to a PCI capable facility, patients arriving from another facility to a non-PCI capable facility have a median wait to coronary angiography of 31 hours longer (68 hours vs 37 hours) and are less likely to have angiography performed within the target timeframe of 72 hours (54% vs 78%). Analysis was only possible in a proportion of NSTEMI cases as records with missing data or specific exclusion criteria were omitted. This detail is available in the clinical indicator section of this report.

Table 17: Time to angiography – direct to PCI facility

Site Total cases Total Median Interquartile range Met 72 hour (n) analysed (hours) (hours) target (n) (%) CH 182 157 53 23–112 63.1 TTH 148 127 50 32–83 68.5 MBH 69 60 38 23–70 78.3 SCUH 172 162 28 17–56 84.6 TPCH 340 301 27 14–54 84.4 RBWH 119 94 21 14–34 92.6 PAH 206 169 42 21–76 74.0 GCUH 141 138 43 22–72 74.6 STATEWIDE 1,377 1,208 37 19–68 77.7

2015 2016 2017

CH

TTH

MBH

NGH

SCUH

TPCH

RBWH

PAH

GCUH

STATEWIDE

0% 25% 50% 75% 100% 0% 25% 50% 75% 100% 0% 25% 50% 75% 100%

Figure 17: Proportion of NSTEMI direct presenters receiving angiography within 72 hours, 2015 to 2017

QCOR Annual Report 2017 Page IC 25 These data are similar to those observed in previous QCOR Annual Reports, highlighting the continuing need for overall system improvement and a potential statewide strategy for referring and transferring patients who require coronary angiography following NSTEMI.

Table 18: Time to angiography – interhospital transfers

SITE Total cases Total analysed Median Interquartile range Met 72 hour target (n) (n) (hours) (hours) (%) CH 125 111 73 36–131 47.7 TTH 101 96 71 39–118 52.1 Interventional Cardiology Interventional MBH 58 36 38 25–53 80.6 SCUH 159 133 35 22–67 79.7 TPCH 326 284 72 43–117 50.0 RBWH 244 219 65 46–92 57.5 PAH 472 412 82 54–117 43.2 GCUH 142 80 55 35–84 68.8 STATEWIDE 1,627 1,371 68 41–107 53.9

2015 2016 2017

CH

TTH

MBH

NGH

SCUH

TPCH

RBWH

PAH

GCUH

STATEWIDE

0% 25% 50% 75% 100% 0% 25% 50% 75% 100% 0% 25% 50% 75% 100%

Figure 18: Proportion of NSTEMI interhospital transfers receiving angiography within 72 hours, 2015 to 2017

Page IC 26 QCOR Annual Report 2017 12.6 PCI following presentation with STEMI Acute STEMI is a recognised medical emergency in which time to treatment is critical to both short and long- term outcomes. PCI capable hospitals have therefore developed rapid triage and transfer systems to fast- track STEMI patients into the cardiac catheter laboratory for rapid reperfusion (primary PCI). Decision-making for the method of reperfusion depends on many factors. Timeliness of treatment and patient characteristics indicate which treatment method is appropriate and applicable. If the patient is in a location that allows for timely transportation to a PCI capable hospital, primary PCI is the preferred treatment choice. If the patient is not able to be transported in a timely manner, fibrinolytic therapy is preferable. Interventional Cardiology Interventional Given the time-critical nature of this presentation type, ongoing refinement of hospital and pre-hospital processes is vital to meet the recommended timeframes for reperfusion in STEMI patients. It is important to recognise there remains a large proportion of STEMI patients who do not present to hospital and are not treated with any form of reperfusion therapy, however this element of care is outside the scope of this registry.

12.6.1 First medical contact Across all sites, 58% of patients with a STEMI presented via the Queensland Ambulance Service (QAS). A smaller proportion of patients presented to the emergency department (DEM) of either a PCI (on-site DEM) or non-PCI capable (satellite DEM) facility (8% and 28% respectively). The remaining 7% presented to other facilities such as GP clinics, community health facilities or other outpatient clinics.

QAS Onsite DEM Satellite DEM Other

CH

TTH

MBH

SCUH

TPCH

RBWH

PAH

GCUH

STATEWIDE

0% 25% 50% 75% 100% 0% 25% 50% 75% 100% 0% 25% 50% 75% 100% 0% 25% 50% 75% 100%

Figure 19: Proportion of STEMI cases by first medical contact

QCOR Annual Report 2017 Page IC 27 12.6.2 Clinical presentation In 2017, there were 1,434 documented PCI STEMI cases with more than half (56%) presenting as primary PCI cases and 11% presenting after 12 hours (late presenters). There were 23% of reperfusion-eligible patients who had received fibrinolysis (lysis), including 6% requiring rescue PCI because lysis had been unsuccessful.

Table 19: Proportion of STEMI cases by presentation

Interventional Cardiology Interventional Site Total STEMI Transient STEMI <6 STEMI 6–12 Late Post Rescue PCI (n) STEMI hours hours Presentation successful (failed lysis) (%) (%) (%) (%) lysis (%) (%) CH 139 8.6 48.2 4.3 15.8 16.5 6.5 TTH 104 4.8 50.0 2.9 19.2 18.3 4.8 MBH 35 2.9 17.1 2.9 11.4 60.0 5.7 SCUH 232 12.1 46.1 3.9 6.0 22.4 9.5 TPCH 241 6.2 56.0 3.3 11.6 16.6 6.2 RBWH 95 4.2 55.8 9.5 15.8 12.6 2.1 PAH 388 16.5 47.4 3.6 8.8 17.0 6.7 GCUH 200 4.5 69.0 7.0 11.5 4.0 4.0 STATEWIDE 1,434 9.6 51.7 4.5 11.2 16.8 6.2

Page IC 28 QCOR Annual Report 2017 13 Clinical indicators

The clinical quality indicator program is a valuable focus of QCOR. The indicators outlined in this document have been selected after considering international PCI and STEMI treatment guidelines and are in line with current best practice. Many key guidelines advise the use of defined and validated quality indicators as a means to measure and improve patient care. The clinical indicators reported for diagnostic and interventional cardiology are:

1 Risk adjusted all-cause 30-day mortality post PCI. Cardiology Interventional 2 Proportion of STEMI patients presenting within six hours of symptom onset, who received an intervention within 90 minutes of first diagnostic ECG. 3 Proportion of all NSTEMI patients who received angiography within 72 hours of first hospital admission. 4 Proportion of majorprocedural complications for PCI (perforation requiring intervention, death, tamponade, emergency coronary artery bypass graft or cerebrovascular accident-stroke). 5 Proportion of cases where total entrance dose exceeded the high dose threshold (5Gy).

QCOR Annual Report 2017 Page IC 29 13.1 Mortality outcomes

13.1.1 Risk adjusted all-cause 30-day mortality post PCI This clinical indicator includes all patients who die within 30 days of a PCI procedure. It does not necessarily indicate a causal relationship between the PCI procedure and the subsequent death. Overwhelmingly, death in these patients occurs despite successful PCI being performed, from the underlying condition for which PCI is being done. Table 20 presents unadjusted mortality according to admission status. As should be expected, the risk of Interventional Cardiology Interventional death increases according to the severity of the patient’s condition (admission status). There were no deaths among stable patients undergoing elective PCI; conversely, mortality was 51% in the critically ill patients who underwent salvage PCI. The overall 30-day unadjusted mortality rate for patients undergoing PCI procedures at hospitals participating in the QCOR analysis for 2017 was 1.9%. This result compares favourably with the 30-day mortality rate of 2.8% presented by the British Cardiovascular Interventional Society (BCIS) in their review of PCI outcomes for the 2014 calendar year (chosen as the comparator as BCIS reports in subsequent years have given in-hospital rather than 30-day mortality).6

Table 20: All-cause unadjusted mortality within 30 days post PCI by admission status

Site Elective Urgent Emergency Salvage Case count Total deaths n (%) n (%) n (%) n (%) (n) n (%) CH 0 (0) 1 (0.4) 2 (1.9) 6 (42.9) 501 9 (1.8) TTH 0 (0) 2 (0.8) 1 (1.4) 1 (33.3) 398 4 (1.0) MBH 0 (0) 1 (0.8) 0 (0.0) – 258 1 (0.4) SCUH 0 (0) 1 (0.3) 7 (3.7) 2 (100.0) 592 10 (1.7) TPCH 0 (0) 6 (1.2) 13 (6.7) 3 (100.0) 1,066 22 (2.1) RBWH 0 (0) 2 (0.8) 2 (2.4) 11 (91.7) 425 15 (3.5) PAH 0 (0) 5 (0.9) 14 (5.4) 0 (0.0) 1,004 19 (1.9) GCUH 0 (0) 0 (0.0) 10 (5.2) 1 (12.5) 684 11 (1.6) STATEWIDE 0 (0) 18 (0.7) 49 (4.4) 24 (51.1) 4,928 91 (1.9) % of total cases by presentation and site

Figure 20 presents the observed mortality rates by site, superimposed on the predicted mortality rates (with 95% confidence interval) calculated using the Victorian Cardiac Outcomes Registry (VCOR) risk adjustment model.7 (This analysis used an imputed dataset accounting for missing data; for TPCH, the nature of the distribution of the missing data precludes calculation of a predicted rate).

Page IC 30 QCOR Annual Report 2017 Reassuringly, mortality rates from all sites are within the expected range for their respective risk-adjusted mortality rates. This is despite the limited risk adjustment model, which only adjusts for 6 factors – ACS, age, LAD involvement, eGFR, LVEF, and cardiogenic shock. Other critical presentations with very high mortality risk, such as out of hospital ventricular fibrillation (VF) arrest with uncertain neurological recovery, are not adjusted for and therefore the model is likely to underestimate true mortality risk. This is relevant in our dataset, where there were marked differences between hospitals in the proportion of high-risk salvage patients taken for PCI. This ranged from 0.3% of cases at SCUH and TPCH, to 2.8% of cases at CH and RBWH. Interventional Cardiology Interventional

CH TTH MBH SCUH TPCH RBWH PAH GCUH

Legend: Observed Predicted (95% confidence interval)

Figure 20: Comparison of observed and predicted mortality rates by site

There were also marked differences in salvage case mortality rates across different hospitals (Table 20). This variation may relate to differences in case-mix at different hospitals, differences in the threshold for performing PCI in critically ill unstable patients, differences in classification of admission status, or a combination of all three factors. Given this variation, and the inability of our current risk prediction model to accurately predict expected mortality in the extreme-risk salvage category, Figure 21 presents the observed and predicted mortality rates excluding salvage.

CH TTH MBH SCUH TPCH RBWH PAH GCUH

Legend: Observed Predicted (95% confidence interval)

Excludes salvage cases (n=46) Figure 21: Comparison of observed and predicted mortality rates by site, excluding salvage

QCOR Annual Report 2017 Page IC 31 As was outlined in the 2016 report, poorly calibrated risk adjustment is known to introduce bias into the monitoring process. Great care, therefore, needs to be exercised in the choice and use of risk adjustment tools to ensure they are relevant and have adequate performance for the patient cohort under scrutiny. Unfortunately, there are very few universally accepted risk models in interventional cardiology. We determined the VCOR model for risk adjustment of 30-day mortality to have the greatest utility for our dataset, compared to other models such as those of the BCIS6, and the American College of Cardiology (ACC) CathPCI registry.8 These models are critically dependant on completeness of data elements. Further effort is needed from all participating sites to improve the completeness of the datasets. With an expanded dataset of reliable data, a more thorough evaluation of the available risk models (BCIS, Interventional Cardiology Interventional ACC, and VCOR) can be explored. This would allow us to recalibrate and adapt one of these models to the specific characteristics of our QCOR dataset, or develop a new, locally relevant model. The variation in salvage cases between different hospitals highlights the importance of this. Some of these cases are STEMI complicated by out of hospital VF arrest, where there is a high yet uncertain chance of dying from a non- cardiac cause (hypoxic brain injury). Small differences in the caseload of such patients, or variation in the likelihood of taking such cases for PCI, would have an undue effect on mortality rates, and yet there is no adjustment for this in the VCOR risk prediction model we are currently applying. In the ideal model, factors which are known to impact on patient outcomes and which are beyond the control of the clinician or service being monitored, are either controlled for in the analysis, or excluded. In measuring performance outcomes, it is important to maintain focus on the process under scrutiny (PCI outcomes), without distortion by uncorrected bias.

Page IC 32 QCOR Annual Report 2017 13.1.1 All STEMI mortality A separate analysis was performed to assess mortality in patients presenting with STEMI. Of the 1,719 documented STEMI cases in 2017, 1,434 cases (83%) included a PCI intervention and are the subject of the following outcomes analyses. For this analysis, patients presenting as salvage are excluded, which allows focus to be retained on the measurement of PCI outcomes. The outcomes for cohort of STEMI patients who underwent primary PCI remain encouraging. All-cause mortality rates at 30 days varied from 1.6% to 3.8% with a statewide rate of 3.1%. Of these 1,398 patients analysed, a total of 44 mortalities were recorded using death registry linkage. The majority (89%) of mortalities occurred in-hospital. Cardiology Interventional

Table 21: STEMI mortality up to 30 days in patients who underwent primary PCI

Site Total cases* In lab In hospital Post discharge to Total (n) (n) (n) 30 days n (%) (n) CH 129 0 2 0 2 (1.6) TTH 101 0 1 1 2 (2.0) MBH 35 0 1 0 1 (2.9) SCUH 230 0 6 1 7 (3.0) TPCH 238 1 8 0 9 (3.8) RBWH 87 0 2 0 2 (2.3) PAH 386 2 11 0 13 (3.4) GCUH 192 0 7 0 7 (3.6) STATEWIDE 1,398 3 39 2 44 (3.1) * Excludes STEMI salvage cases (n=36)

13.1.2 STEMI presentation within 6 hours from symptom onset Further analysis of the STEMI cohort who underwent primary PCI within 6 hours of symptom onset demonstrates all-cause 30-day mortality rates between 0% and 4.5% across centres, with the statewide rate at 3.7%. For this analysis, patients presenting as high-risk salvage cases have been excluded.

Table 22: STEMI mortality up to 30 days for patients who underwent a primary PCI and presented within 6 hours of symptom onset

Site Total cases* In lab In hospital Post discharge to Total (n) (n) (n) 30 days n (%) (n) CH 61 0 1 0 1 (1.6) TTH 51 0 1 0 1 (2.0) MBH 6 0 0 0 0 (0) SCUH 105 0 4 1 5 (4.8) TPCH 133 1 5 0 6 (4.5) RBWH 48 0 1 0 1 (2.1) PAH 184 2 6 0 8 (4.3) GCUH 134 0 4 0 4 (3.0) STATEWIDE 723 3 23 1 27 (3.7) * Excludes STEMI presenting within 6 hours of symptom onset salvage cases (n=19)

QCOR Annual Report 2017 Page IC 33 13.2 STEMI less than 6 hours from symptom onset – time to reperfusion The most critical factor influencing outcome for patients who experience a STEMI is the total ischaemic time, defined as the time interval from symptom onset to successful reperfusion. The exact time of symptom onset is often difficult to ascertain, and the time between symptom onset and call for help is primarily a patient- dependent factor. Therefore, STEMI guidelines worldwide now advocate first diagnostic ECG (FdECG)-to-device time as an important modifiable and objective measure of overall STEMI system performance.9

Interventional Cardiology Interventional Both the European and American STEMI guidelines recommend a target FdECG-to-device time less than 90 minutes. For patients who present initially to a non-PCI hospital then transfer to a PCI facility (inter-hospital transfer), the accepted FdECG-to-device target is less than 120 minutes.9,10 It is widely recognised that these targets are ambitious and difficult to achieve in real-world practice as primary PCI becomes more available to larger catchment populations. Achieving these times requires efficient coordination of care within and between the ambulance service and transferring/receiving hospitals. Accepted strategies to improve reperfusion times include pre-hospital activation of the cardiac catheter laboratory, an immediate response of the on-call PCI team to be operational within 30 minutes of alert and bypass of the emergency department.

Table 23: Definitions for STEMItime to reperfusion

Time Definition First diagnostic ECG First diagnostic ECG refers to the timestamp when the ECG shows ST-segment elevation (or equivalent) and can be regarded as time zero in the therapeutic pathway. The interpretation of the first diagnostic ECG may be undertaken by ambulance personnel, general practitioners or hospital-based medical staff. Door time Door time refers to the timestamp when the patient presents to the PCI hospital and can be regarded as time zero in the therapeutic pathway for patients presenting via this method. First device time The first device time, as a surrogate for reperfusion, is the first timestamp recorded of the earliest device used: • first balloon inflation, or • first stent deployment, or • first treatment of lesion (thrombectomy/aspiration device, rotational atherectomy) If the lesion cannot be crossed with a guidewire or device (and thus none of the above applies), the time of guidewire introduction is used. If there is already TIMI 3 flow observed on initial angiography, that timestamp is used instead of first device.

Page IC 34 QCOR Annual Report 2017 The steering committee established the benchmark target of 75% of patients to receive timely reperfusion measured from first diagnostic ECG to reperfusion as well as from arrival at PCI facility to reperfusion. In total, there were 742 STEMI primary PCI cases presenting within six hours of symptom onset. Of these, there were 126 cases which had been excluded per the criteria in Table 24 leaving 616 cases which are eligible for the following analysis. Further cases are excluded from the clinical indicators where the timestamps required to measure time to reperfusion were not recorded in the system. Considerable variation was observed depending on the admission pathway to the treating facility.

FdECG to reperfusion Cardiology Interventional Admission pathway Total cases (n) (minutes)

Interhospital transfer 39 106

Other 47 94

QAS direct to treating facility 359 86

Onsite DEM 44 68.5

STATEWIDE 489 86

0 10 20 30 40 50 60 70 80 90 100 110 Minutes

Other includes GP, inpatient and outpatient referrals Figure 22: STEMI presenting within 6 hours of symptom onset – median first diagnostic ECG to first device time by admission pathway

Table 24: STEMI <6 hours cases ineligible for analysis

Summary n Out of hospital arrest 34 Salvage 19 Significant comorbidities/frailty 16 Previous coronary artery bypass graft surgery 14 Thrombolysis contraindicated 12 Intubation 12 Shock/acute pulmonary oedema 12 Unsuccessful PCI 4 Significant non-cardiac comorbidity 3 Total ineligible 126

QCOR Annual Report 2017 Page IC 35 13.2.1 Time from first diagnostic ECG to first device The all-site median time from first diagnostic ECG to reperfusion was 86 minutes, with median individual site times ranging from 70 minutes to 98 minutes. These results indicate that overall Queensland public facilities are approaching the ambitious benchmark of 90 minutes from time of first diagnostic ECG to first device. However, only 57% of patients analysed receive timely reperfusion per current guidelines (FdECG to reperfusion)6, supporting the view that the current target is optimistic. This is currently the focus of international review as more achievable objectives are explored. Nonetheless, the metric of time to reperfusion remains a useful tool for monitoring processes and efficiencies and

Interventional Cardiology Interventional demonstrates the potential for improvement or maintenance of system and hospital performance.

Table 25: First diagnostic ECG (FdECG) to reperfusion for STEMI presenting within 6 hours of symptom onset

SITE Total cases Total analysed Median Interquartile range Met 90 min target (n) (n) (minutes) (minutes) (%) CH 67 51 70 60–87 74.5 TTH 52 44 76 63–95 70.5 MBH* 6 3 – – – SCUH 107 88 88 72–106 58.0 TPCH† 135 0 – – – RBWH 53 44 82 66–101 65.9 PAH 184 145 98 84–114 39.3 GCUH 138 114 84 69–99 61.4 STATEWIDE 742 489 86 71–106 56.6 * MBH is not displayed as it has <20 cases for analysis † TPCH is not included as it has not collected FdECG timestamps until 2018

2015 2016 2017

CH

TTH

NGH

SCUH

RBWH

PAH

GCUH

STATEWIDE

0% 25% 50% 75% 100% 0% 25% 50% 75% 100% 0% 25% 50% 75% 100%

Figure 23: Proportion of STEMI cases (<6 hours of symptom onset) where time from first diagnostic ECG to reperfusion met 90 minute target, 2015–2017

Page IC 36 QCOR Annual Report 2017 1. Pre-hospital notification processes The Queensland Ambulance Service has a long-established record of developing pre-hospital processes for the management of STEMI. On recognition of STEMI meeting criteria for primary PCI by a QAS paramedic trained in coronary reperfusion, direct contact is made with the on-call interventional cardiologist of the receiving hospital via a dedicated referral line. A pre-hospital treatment plan is agreed and the cardiac catheter lab is activated. This referral, however, could not occur if a QAS paramedic trained in coronary reperfusion was not available to attend the patient. Since 2008, Critical Care Paramedics have always been trained in reperfusion and more recently, QAS has

implemented a strategy to provide this training to all Advanced Care Paramedics to promote faster activation Cardiology Interventional of the cardiac catheter lab for more STEMI patients. It is likely that as this strategy takes effect, more STEMI patients will be referred earlier.

Median pre-hospital Site Total analysed (n) component

CH 13 43 mins 4 25 14

TTH 19 40 mins 7 22 11

SCUH 51 51 mins 7 24 20

TPCH 81 55 mins 6 26 23

RBWH 27 45 mins 6 27 12

PAH 129 57 mins 6 29 22

GCUH 75 44 mins 5 24 15

STATEWIDE 397 51 mins 6 26 19

0 10 20 30 40 50 60 Minutes

Legend: QAS arrival to STEMI STEMI recognised to Depart scene to arrive recognised depart scene PCI facility

MBH not displayed due to <10 cases available for analysis Figure 24: STEMI under 6 hours pre-hospital component breakdown – QAS direct to PCI facility

2. Hospital processes All hospitals have established pathways for notification of and receiving STEMI patients. Some hospital processes vary across the state depending on factors including the time of day or the local requirement of some patients to transit via the Emergency Department. Although differing processes may explain some variation, this would appear to have minimal impact: when exploring door to device times in the following section, all sites were similar in the time taken to treat patients once they arrived at the PCI capable facility.

QCOR Annual Report 2017 Page IC 37 13.2.2 Time from arrival PCI capable facility to first device The time between PCI hospital arrival and reperfusion (‘door-to-device time’) is currently the accepted measure of PCI hospital system performance in STEMI. Historically, hospitals have worked to a goal of less than 90 minutes, although more recent guidelines have shortened this target time to less than 60 minutes.7,10 Results demonstrate that for over half of cases (69%), participating PCI facilities are meeting a target door-to- device time of less than 60 minutes, with an overall all-site median time of 46 minutes (range 34 minutes to 60 minutes).

Interventional Cardiology Interventional Table 26: Arrival at PCI hospital to first device for STEMI presenting within 6 hours of symptom onset

SITE Total cases Total analysed Median Interquartile range Met 60 min target (n) (n) (minutes) (minutes) (%) CH 67 47 54 33–75 57.4 TTH 52 43 60 43–87 51.2 MBH 6 3 – – – SCUH 107 87 34 25–58 77.0 TPCH 135 118 39 30–64 73.7 RBWH 53 42 48 35–81 69.0 PAH 184 145 44 32–57 77.9 GCUH 138 106 52 36–78 59.4 STATEWIDE 742 591 46 31–67 69.2 * MBH is not displayed as it has <20 cases for analysis

CH

TTH

NGH

SCUH

TPCH

RBWH

PAH

GCUH

STATEWIDE

0% 25% 50% 75% 100% 0% 25% 50% 75% 100% 0% 25% 50% 75% 100%

Figure 25: Proportion of cases where door to device ≤60 minutes was met for STEMI presenting within 6 hours of symptom onset, 2015–2017

Page IC 38 QCOR Annual Report 2017 13.3 NSTEMI – time to angiography Coronary angiography is necessary to determine the severity of coronary disease with both quality of life and prognostic implications for patients presenting with non-ST elevation acute coronary syndromes. National and international guidelines recommend that coronary angiography should be offered and performed within 72 hours of diagnosis. This duration is reduced to 24 hours for those deemed to be at high risk of major cardiac events.5 For this indicator, the QCOR committee recommended that the treatment timeframe for analysis should be 72 hours in order to capture all patients with the working diagnosis of NSTEMI, acknowledging that a universal risk prediction score has not been applied. Cardiology Interventional Table 27 lists the cases that were excluded from the analysis and the reason for exclusion.

Table 27: NSTEMI time to angiography – cases ineligible for analysis

n Admitted with an unrelated principal diagnosis 127 Planned or staged PCI 104 Transferred from an interstate hospital 69 Coronary angiography not performed at index admission 37 Transferred from a private hospital 32 Stable non-admitted patients transferred directly to lab for planned angiography 23 Incomplete data 32 Total ineligible 424

QCOR Annual Report 2017 Page IC 39 The median time to angiography with or without PCI was 53 hours (direct transfers 37 hours vs inter-hospital transfers 68 hours). Of the 3003 NSTEMI cases, 54% were inter-hospital transfers and, 47% received PCI. Figure 26 depicts the proportions of cases meeting the Committee target. Across the state, the baseline for each PCI centre likely reflects the demographics, logistics and pathways that pertain to that centre. Overall, there appears to be better performance from year to year with room for improvement that may be maximised by auditing local practice.

Table 28: NSTEMI time to angiography by site

Interventional Cardiology Interventional SITE Total NSTEMI Total analysed Median Interquartile Met 72 hour cases (n) (hours) range target (n) (hours) (%) CH 307 268 62 27–115 56.7 TTH 249 223 60 35–95 61.4 MBH 127 96 38 23–68 79.2 SCUH 331 295 33 20–61 82.4 TPCH 665 585 47 22–88 67.7 RBWH 363 313 54 27–84 68.1 PAH 678 581 70 42–110 52.2 GCUH 283 218 49 24–77 72.5 STATEWIDE 3,003 2,579 53 26–91 65.1

2015 2016 2017

CH

TTH

MBH

NGH

SCUH

TPCH

RBWH

PAH

GCUH

STATEWIDE

0% 25% 50% 75% 100% 0% 25% 50% 75% 100% 0% 25% 50% 75% 100%

Figure 26: Proportion of NSTEMI cases meeting time to angiography target of 72 hours, 2015–2017

Page IC 40 QCOR Annual Report 2017 13.4 Major procedural complications This quality indicator examines in lab intra-procedural complications. In 2017, 24 cases (0.49%) recorded an immediate major procedural complication. Events included in this analysis are coronary artery perforation, in-lab death, pericardial tamponade, emergency coronary artery bypass graft surgery and cerebrovascular accident. Overall, the numbers are far too low for further comment, other than to state that it is obviously reassuring.

% Interventional Cardiology Interventional

%

%

%

Figure 27: Documented immediate major procedural complications by site

Table 29: All PCI cases by immediate major procedural complication type

Major complication type Count % Coronary artery perforation 18 0.37 In lab death 4 0.08 Tamponade 1 0.02 Emergency CABG 1 0.02 Cerebrovascular accident 0 0.00 No immediate major procedural complication 4,904 99.51 Total 4,928 100.00

QCOR Annual Report 2017 Page IC 41 13.5 Safe radiation doses Staff and patients are exposed to ionising radiation during almost all procedures performed in the cardiac catheter laboratory. Whilst ionising radiation is known to cause both delayed and deterministic (non-delayed) effects, the probability of effect is thought to be dose-related. Fortunately, conservative thresholds are applied and monitored throughout Queensland. However, as the complexity of procedural work undertaken by interventional cardiologists increases, along with the increase in patients with a large body mass, it is increasingly important to remain vigilant about radiation hygiene. This indicator examines the proportion of cases exceeding the high dose threshold of 5Gy. Interventional Cardiology Interventional

Table 30: Proportion of cases meeting the safe dose threshold by case type

Site PCI procedures Other coronary procedures (%) (%) CH 99.8 100.0 TTH 98.5 100.0 MBH 100.0 100.0 SCUH 99.3 99.9 TPCH 97.8 99.9 RBWH 98.1 100.0 PAH 94.2 99.8 GCUH 99.7 99.9 STATEWIDE 97.9 99.9

Page IC 42 QCOR Annual Report 2017 14 Conclusions

This 2017 report continues to demonstrate encouraging results for all public cardiac catheter laboratory sites across Queensland. Of the 8 sites it is apparent that there are reassuring mortality and morbidity rates observed despite a varied and sometimes complex cohort of presenting patients.

Collection of supporting risk adjustment data continues to be a challenge given that some of these data elements may not be readily available at the time of urgent or emergency procedures. The efforts of site Interventional Cardiology Interventional quality improvement coordinators and data managers are to be commended however, with rates of data completion showing promising improvement throughout 2017. It is hoped that the QCOR data quality audit program will be extended to encompass all sites in the future to facilitate full analyses of risk adjusted outcomes.

The input of the Queensland Ambulance Service in this year’s report further demonstrates the positive relationship between the two Government Departments continuing to produce encouraging results. This collaboration will hopefully be the basis for further opportunities for service improvement across both clinical services with the focus on optimising patient outcomes.

With the results demonstrated across all clinical indicators and benchmark activities, Queenslanders can be assured of treatment that exceeds international benchmarks and that the registries developed to promote this care are providing the support and evidence clinicians require.

QCOR Annual Report 2017 Page IC 43 15 Recommendations

The development of future reports that document the patient journey between QCOR specialty areas is a point of focus for future work. With linkage of patient presentations and participation across other QCOR applications, it is hoped that an overview of the incidence of patients requiring reinvestigation or repeat revascularisation can be developed.

Development of a new QCOR structural heart disease module remains a priority. The module developed to Interventional Cardiology Interventional provide superior reporting capabilities for structural heart disease interventions including device closure, and percutaneous valve replacement and repair procedures. Use of the new system is expected to commence in early 2019. It is anticipated that this will enable future statewide participation in national quality and safety activities for transcatheter aortic valve replacement as well as offer an unprecedented insight into the quality of care of patients undergoing interventions in this emerging area of cardiac services.

Facilitating the planning and commissioning of new health infrastructure is also a key aim of publications such as this. With the included geographic analysis, including proximity to treating facility in this years’ report, greater insight into the barriers encountered by patients with respect to health access can be demonstrated and should be expanded for future reports. These analyses are particularly pertinent given the current objectives of better cardiac care for all Queenslanders closer to home.

Inclusion of private facilities continues to be an aim for QCOR as a whole, with a particular desire for participation in the interventional cardiology audit program apparent. Future work will be focused on facilitating this participation. Queensland’s participation in national registries also continues to be a focus for the group. With the development of a new framework for a nationwide cardiac registry underway, Queensland interventional cardiology practitioners are eagerly awaiting the opportunity to contribute to this important initiative.

Page IC 44 QCOR Annual Report 2017 16 Supplement: Structural heart disease

The QCOR structural heart disease (SHD) initiative is a continued focus of the the QCOR interventional cardiology committee with the development of a bespoke QCOR module catering towards these procedures underway. The new module has been developed to provide clinicians with enhanced procedure reporting capabilities at the point of care with prospective clinical use expected to commence in early 2019. This QCOR supplementary report has expanded to encompass SHD interventions performed across all Queensland public cardiac catheterisation laboratories in 2017. In future it is hoped that the registry would be able to extend participation toward private facilities as well. Cardiology Interventional

16.1 Participating sites In 2017, there were seven participating cardiac catheter laboratories performing a total of 390 SHD interventions.

Table 1: Total SHD cases by participating site

Site Device closure* Valvular intervention† Other‡ All cases n (%) n (%) n (%) n (%) CH 13 (72.2) 5 (27.8) - 18 (100.0) TTH 10 (62.5) 6 (37.5) - 16 (100.0) SCUH 7 (77.8) 2 (22.2) - 9 (100.0) TPCH 50 (17.9) 218 (78.1) 11 (3.9) 279 (100.0) RBWH 1 (33.3) 2 (66.7) - 3 (100.0) PAH 15 (29.4) 33 (64.7) 3 (5.9) 51 (100.0) GCUH 5 (35.7) 9 (64.3) - 14 (100.0) STATEWIDE 101 (25.9) 275 (70.5) 14 (3.6) 390 (100.0) * Includes percutaneous closure of ASD, PFO, PDA, LAA, paravalvular leak and VSD † Percutaneous valve replacement and valvuloplasty ‡ Myocardial septal ablation, ASD balloon occlusion and percutaneous insertion of pulmonary arterial pressure monitoring device

QCOR Annual Report 2017 Page IC 45 16.2 Patient characteristics

16.2.1 Age and gender Patients undergoing an SHD intervention were almost evenly distributed between genders at 54% male and 46% female. Age varied considerably by procedure category, with patients undergoing a valvular intervention having an overall median age of 82 years compared to 49 years for device closure procedures. Interventional Cardiology Interventional

Male Female

≥85

80-84

75-79

70-74

65-69

60-64

55-59

50-54

45-49

40-44

<40

15% 10% 5% 0% 0% 5% 10% 15%

% of total (n=390) Figure 1: Proportion of all SHD cases by gender and age group

Table 2: Median age by gender and procedure category

Male Female All cases (years) (years) (years) Device closures 50 49 49 Valvular intervention 82 83 82 Other 63 63 63 ALL 79 80 79

Page IC 46 QCOR Annual Report 2017 16.3 Care and treatment of SHD patients

16.3.1 Device closures In 2017 there were a total of 101 device closures performed across participating centres. The most common procedures were for the correction of a patent foramen ovale (PFO), followed by atrial septal defect (ASD) at 40% and 36% of overall case volumes respectively.

Table 3: Device closure procedures by participating site Interventional Cardiology Interventional Site Aortic ASD* PDA† LAA‡ Para- PFO§ VSD|| All Pseudo- n (%) n (%) n (%) valvular n (%) n (%) n (%) aneurysm leak n (%) n (%) CH - 5 (38.5) - - - 8 (61.5) - 13 (100.0) TTH - 7 (70.0) - - - 3 (30.0) - 10 (100.0) SCUH - 2 (28.6) - - 1 (14.3) 4 (57.1) - 7 (100.0) TPCH 2 (4.0) 12 (24.0) 3 (6.0) 11 (22.0) 3 (6.0) 17 (34.0) 2 (4.0) 50 (100.0) RBWH - 1 (100.0) - - - - - 1 (100.0) PAH - 8 (53.3) - - 2 (13.3) 4 (26.7) 1 (6.7) 15 (100.0) GCUH - 1 (20.0) - - - 4 (80.0) - 5 (100.0) STATEWIDE 2 (2.0) 36 (35.6) 3 (3.0) 11 (10.9) 6 (5.9) 40 (39.6) 3 (3.0) 101 (100.0) * Atrial septal defect † Patent ductus arteriosus (includes 2 device closures and 1 device coiling of PDA) ‡ Left atrial appendage § Patent foramen ovale || Ventricular septal defect

QCOR Annual Report 2017 Page IC 47 16.3.2 Valvular interventions In 2017, there were 275 valvular interventions performed across 7 participating sites. Valvular interventions comprised of transcatheter valvular repair (Table 6) and transcatheter valve replacement (Table 7) procedures. Valvular interventions were almost evenly distributed with 137 transcatheter valve replacements and 138 transcatheter valve repairs. The aortic valve was the most common valve requiring intervention and accounted for 86% of overall cases and majority of cases across all participating sites.

Aortic Interventional Cardiology Interventional

Mitral

Pulmonary

Tricuspid

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 2: Proportion of all transcatheter valvular interventions by valve type

Table 4: Transcatheter valvular interventions by type of valve

Site Aortic Mitral Pulmonary Tricuspid All cases n (%) n (%) n (%) n (%) n (%) CH 5 (100.0) - - - 5 (100.0) TTH 4 (66.7) 2 (33.3) - - 6 (100.0) SCUH 2 (100.0) - - - 2 (100.0) TPCH 184 (84.4) 26 (11.9) 5 (2.3) 3 (1.4) 218 (100.0) RBWH 2 (100.0) - - - 2 (100.0) PAH 30 (90.9) 1 (3.0) 2 (6.1) - 33 (100.0) GCUH 9 (100.0) - - - 9 (100.0) STATEWIDE 236 (85.8) 29 (10.5) 7 (2.5) 3 (1.1) 275 (100.0)

Table 5: Transcatheter valvular interventions

Site Transcatheter valvuloplasty Transcatheter valve All cases n (%) replacement n (%) n (%) CH 5 (100.0) - 5 (100.0) TTH 6 (100.0) - 6 (100.0) SCUH 2 (100.0) - 2 (100.0) TPCH 107 (49.1) 111 (50.9) 218 (100.0) RBWH 2 (100.0) - 2 (100.0) PAH 11 (33.3) 22 (66.7) 33 (100.0) GCUH 5 (55.6) 4 (44.4) 9 (100.0) STATEWIDE 138 (50.2) 137 (49.8) 275 (100.0)

Page IC 48 QCOR Annual Report 2017 Table 6: Transcatheter interventional valve procedures

Site Balloon Balloon MitraClip PASCAL REDUCE FMR Balloon Balloon aortic mitral n (%) n (%) Trial pulmonary tricuspid valvuloplasty valvuloplasty n (%) valvuloplasty valvuloplasty n (%) n (%) n (%) n (%) CH 5 (100.0) ------TTH 4 (66.7) 2 (33.3) - - - - - SCUH 2 (100.0) ------TPCH 81 (75.7) 3 (2.8) 12 (11.2) 3 (2.8) 4 (3.7) 1 (0.9) 3 (2.8) Interventional Cardiology Interventional RBWH 2 (100.0) ------PAH 9 (81.8) 1 (9.1) - - - 1 (9.1) - GCUH 5 (100.0) ------STATEWIDE 108 (78.3) 6 (4.3) 12 (8.7) 3 (2.2) 4 (2.9) 2 (1.4) 3 (2.2)

Table 7: Transcatheter valve replacement procedures

Site TAVR* TMVR† TPVR‡ n (%) n (%) n (%) TPCH 103 (92.8) 4 (3.6) 4 (3.6) PAH 21 (95.5) - 1 (4.5) GCUH 4 (100.0) - - STATEWIDE 128 (93.4) 4 (2.9) 5 (3.6) * Transcatheter aortic valve replacement † Transcatheter mitral valve replacement ‡ Transcatheter pulmonary valve replacement

Table 8: Other structural heart disease interventions

Site ASD* balloon occlusion Myocardial septal ablation Pulmonary arterial pressure n (%) n (%) monitoring device n (%) TPCH 1 (9.1) 5 (45.5) 5 (45.5) PAH - 3 (100.0) - STATEWIDE 1 (7.1) 8 (57.1) 5 (35.7) * Atrial septal defect

QCOR Annual Report 2017 Page IC 49 16.4 Patient outcomes

16.4.1 All cause 30 day mortality For the participating sites performing structural heart disease interventions within 2017, there was an overall all cause unadjusted mortality rate within 30 days of 4.1%.

Table 9: All cause unadjusted 30 day mortality post SHD intervention by procedure category and site

Interventional Cardiology Interventional Site Total cases Device closure Valvular Other Total deaths (n) n (%) intervention n (%) n (%) n (%) CH 18 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) TTH 16 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) SCUH 9 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) TPCH 279 1 (2.0) 12 (5.5) 1 (9.1) 14 (5.0) RBWH 3 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) PAH 51 1 (6.7) 1 (3.0) 0 (0.0) 2 (3.9) GCUH 14 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) STATEWIDE 390 2 (2.0) 13 (4.7) 1 (7.1) 16 (4.1)

16.4.2 All TAVR cases

2017 cases Of the three sites performing TAVR in 2017, the overall all cause unadjusted mortality rate within 30 days of the procedure was 3.1%.

Table 10: All cause unadjusted 30 day mortality post SHD intervention by site

Site Total cases 30 day mortality (n) n (%) TPCH 103 4 (3.9) PAH 21 0 (0.0) GCUH 4 0 (0.0) STATEWIDE 128 4 (3.1)

2016 cases Of the two sites performing TAVR within 2016, the overall all cause unadjusted mortality rate within 30 days of the procedure was 1.0%, and 9.8% at 365 days.

Table 11: All cause unadjusted 30 day and 365 day mortality post SHD intervention by site, 2016

Site Total cases 30 day mortality 365 day mortality (n) n (%) n (%) TPCH 86 1 (1.1) 9 (10.3) PAH 15 0 (0.0) 1 (6.7) STATEWIDE 101 1 (1.0) 10 (9.8)

Page IC 50 QCOR Annual Report 2017 Cardiac Surgery Audit Cardiac Surgery Cardiac

QCOR Annual Report 2017 Page CS 1 Cardiac Surgery Cardiac

Page CS 2 QCOR Annual Report 2017 17 Message from the QCOR Cardiothoracic Committee Chair

With this report on cardiac surgery in Queensland in 2017, we continue the project of ensuring that each individual Queenslander who faces the daunting prospect of cardiac surgery is receiving the best level of care we can provide as cardiac surgical teams. Since the 2016 report, there have been several changes. Where the 2016 report only included data from three hospitals, the 2017 report includes all public units in Queensland that perform cardiac surgery. Apart from reporting a standard set of data about activity and demographics, particular subsets of cardiac surgical conditions have been identified by the committee as deserving detailed reporting. Detailed reports on particular conditions allow us to identify information gaps in the database, information that once we start to collect can assist in targeting strategies to change the incidence of treatment of that disease. For this report, our detailed report is on endocarditis. Being a surgical database, this means the data is restricted to patients who have had surgery for endocarditis. The QCOR project as a whole serves as the denominator for conditions for which surgery is the numerator. Understanding which patients undergo resource intensive surgery for particular conditions allows us to serve as a guide for those who would seek to improve health Surgery Cardiac outcomes for Queenslanders, particularly for health conditions that have preventable aspects, such as illicit intravenous drug use. All surgical units now contribute directly to the QCOR cardiac surgery database directly through the web portal. The database is being improved by the addition of new data points, but also by adding the ability for individual units to generate reports themselves on their unit data, rather than requesting a report through the database team. This allows for individual units to rapidly answer unit specific queries, guiding changes their systems and processes. The QCOR database is a conduit to the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) database, with all data from the QCOR cardiac surgery database submitted to the national database, which itself undertakes quality assurance activities, further reassuring Queenslanders that our performance as cardiac surgical teams is well within expected levels of performance. Analysis of individual unit and surgeon performance is done through the ANZSCTS database, with a well-established feedback loop and quality assurance programme. The individual units and the committee have reviewed individual cases of, and the incidence of deep sternal wound infections (DSWI) in 2016, and report on these findings in this report. The issue with DSWI arose because of our analysis of 2016 that used an American based risk score. That this risk score does not seem to be predictive in our patients demonstrates one of the issues with reliance on risk scores to justify decision making. This is particularly relevant to cardiac surgery and cardiology because risk scores are often used to justify decisions for and against either open surgical options or catheter-based techniques. With each iteration of this report, we seek to improve the report itself and hope that the addition of a detailed supplemental report achieves this aim.

Dr Christopher Cole Chair QCOR Cardiothoracic Surgery Committee

QCOR Annual Report 2017 Page CS 3 18 Key findings

This second Queensland cardiac surgery audit describes baseline demographics, risk factors, surgeries performed and surgery outcomes for 2017. Key findings include: • In 2017, 2,364 surgeries were performed across the 4 public adult cardiac surgery units in Queensland. • The majority of patients were between 61 years and 80 years of age (61%) with a median age of 66 years old. • Approximately three-quarters of patients were male (74%). • The majority of all patients were overweight or obese (74%). • The proportion of Indigenous patients overall was 7.1%, however there was wide variation with 24% of patients in Townsville identifying as Aboriginal and Torres Strait Islander.

Cardiac Surgery Cardiac • Smoking and hypertension were present in over half of all coronary artery bypass graft (CABG) patients and diabetes in around one quarter of all patients (27%). • 18% of patients were current smokers at the time of their operation. • 30% of patients had an element of left ventricular dysfunction. • 52% of patients were elective admissions. • Same day admission rates for elective surgery were 14% for all surgery types. • Over half (61%) of all cardiac surgery procedures included a CABG. • 30% of elective cases required blood products compared to 77% of emergency cases. • Mitral valve repair (66%) was the most common form of valve repair surgery and aortic valve replacement (75%) the most frequently performed replacement surgery. • The average number of bypass grafts used was 2.7. In multi-vessel CABG the mean number increased to 2.9. • Calcific valve disease (49%) was the primary pathology for aortic valve replacement with myxomatous disease (36%) the most frequently encountered pathology leading to mitral valve intervention. • The mortality rate after surgery is significantly less than expected, depending on the risk model used to evaluate this outcome. • Major morbidities were evaluated using STS models with most results demonstrating that the observed rate of adverse events is within expectations.

Page CS 4 QCOR Annual Report 2017 Cardiac Surgery Audit Cardiac Surgery Audit

19 Participating sites

In 2017, there were 4 public cardiac surgery units spread across metropolitan and regional Queensland all of which entered data directly into the QCOR cardiac surgery database. Patients came from a wide geographical area, with the majority of patients residing on the Eastern Seaboard. Cardiac Surgery Cardiac

Figure 1: Cardiac surgery cases by residential postcode

Table 1: Participating sites

Site Number Site Name Location Acronym 1 The Townsville Hospital Regional TTH 2 The Prince Charles Hospital Metropolitan TPCH 3 Princess Alexandra Hospital Metropolitan PAH 4 Gold Coast University Hospital Metropolitan GCUH

QCOR Annual Report 2017 Page CS 5 Cardiac Surgery Cardiac

Figure 2: The Townsville Hospital Figure 3: The Prince Charles Hospital

Figure 4: Princess Alexandra Hospital Figure 5: Gold Coast University Hospital

Page CS 6 QCOR Annual Report 2017 20 Case totals

20.1 Total cases In 2017, 2,364 cardiac surgical procedures were performed across the state at the 4 public hospitals that directly entered data in the QCOR database. Each of the procedure combinations included in those cases have been allocated to a cardiac surgery procedure category for the purpose of this report.

Table 2: Procedure counts and surgery category

Procedure combination Count Category* CABG 1,147 ANY CABG CABG + other cardiac procedure 24 CABG + other non-cardiac procedure 13 CABG + aortic procedure 6

CABG + other cardiac procedure + other non-cardiac procedure 1 Surgery Cardiac CABG + valve 218 CABG + VALVE CABG + valve + aortic procedure 20 CABG + valve + other cardiac procedure 12 CABG + valve + aortic procedure + other cardiac procedure 3 CABG + valve + other non-cardiac procedure 2 Valve procedure† 541 VALVE Valve + aortic procedure 115 Valve + other cardiac procedure 76 Valve + aortic procedure + other cardiac procedure 12 Valve + other non-cardiac procedure 2 Valve + aortic procedure + other non-cardiac procedure 1 Valve + other cardiac procedure + other non-cardiac procedure 1 Other cardiac procedure 106 OTHER Aortic procedure 44 Other cardiac procedure + other non-cardiac procedure 12 Aortic procedure + other cardiac procedure 4 Aortic procedure + other non-cardiac procedure 4 STATEWIDE 2,364 Note, final column outlines allocation of procedures to surgery categories * Category procedure combination allocated † Includes TAVR procedures (n=40)

QCOR Annual Report 2017 Page CS 7 20.2 Cases by category More than half (61%) of all cardiac surgery procedures involved CABG. Of these, 11% involved a simultaneous valve procedure while 50% did not.

ANY CABG CABG + VALVE VALVE OTHER

TTH

TPCH

PAH

GCUH

STATEWIDE

0% 25% 50% 75% 100% 0% 25% 50% 75% 100% 0% 25% 50% 75% 100% 0% 25% 50% 75% 100%

Cardiac Surgery Cardiac Figure 6: Proportion of cases by site and surgery category

Table 3: Proportion of cases by surgery category

SITE ANY CABG CABG + VALVE VALVE OTHER Total cases n (%) n (%) n (%) n (%) n (%) TTH 206 (58.2) 41 (11.6) 91 (25.7) 16 (4.5) 354 (100.0) TPCH 498 (44.8) 131 (11.8) 370 (33.3) 113 (10.2) 1,112 (100.0) PAH 304 (53.1) 56 (9.8) 184 (32.1) 29 (5.1) 573 (100.0) GCUH 183 (56.3) 27 (8.3) 103 (31.7) 12 (3.7) 325 (100.0) STATEWIDE 1,191 (50.4) 255 (10.8) 748 (31.6) 170 (7.2) 2,364 (100.0)

Page CS 8 QCOR Annual Report 2017 21 Patient characteristics

21.1 Age and gender Age is an important risk factor for developing cardiovascular disease. Most patients were aged between 61 and 80 (61%). The male, 70 years to 74 years cohort accounted for the largest proportion of cases (13% of all cases or 17% of males). The median age of all patients undergoing cardiac surgery was 66 years of age. This was similar for both males and females (median age of 66 years and 67 years respectively).

Male Female

≥85

80-84 Cardiac Surgery Cardiac 75-79

70-74

65-69

60-64

55-59

50-54

45-49

40-44

<40

15% 10% 5% 0% 0% 5% 10% 15%

% of total (n=2,364) Figure 7: Proportion of all cases by age group and gender

Table 4: Median age by gender and surgery category

Total cases Male Female ALL (n) (years) (years) (years) ANY CABG 1,191 66 67 66 CABG + VALVE 255 71 72 72 VALVE 748 64 67 66 OTHER 170 55 59 57 STATEWIDE 2,364 66 67 66

QCOR Annual Report 2017 Page CS 9 Overall, around three-quarters of patients were male (74%) with the largest proportion of females represented in the valve and other cardiac surgery categories (35% and 45% respectively). This reflects the increased risk of coronary artery disease in men.

Male Female

ANY CABG

CABG + VALVE

VALVE

OTHER

STATEWIDE

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%

Figure 8: Proportion of cases by gender and surgery category Cardiac Surgery Cardiac

Page CS 10 QCOR Annual Report 2017 21.2 Body mass index Less than one-quarter (24%) of cardiac surgery patients had a healthy body mass index (BMI), while patients having a BMI category of overweight, obese or morbidly obese represented around three quarters of cardiac surgery patients (74%). There were less obese patients in the valve only surgery category (29%) than other categories that include CABG surgery (37% and 36%). Patients classed as underweight (BMI<18.5kg/m2) represented approximately 1% of all cases.

Normal weight* Overweight† Obese‡ Morbidly obese§

ANY CABG

CABG + VALVE

VALVE

OTHER

STATEWIDE Cardiac Surgery Cardiac

0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50%

* BMI 18.5–24.9 kg/m2

† BMI 25–29.9 kg/m2

‡ BMI 30–39.9 kg/m2

§ BMI ≥40 kg/m2 Figure 9: Proportion of cases by BMI and surgery category

Table 5: Proportion of cases by BMI and surgery category

Underweight Normal weight Overweight Obese Morbidly obese n (%) n (%) n (%) n (%) n (%) ANY CABG 8 (0.7) 255 (21.4) 440 (36.9) 436 (36.6) 52 (4.4) CABG + VALVE 1 (0.4) 52 (20.4) 99 (38.8) 92 (36.1) 11 (4.3) VALVE 13 (1.7) 207 (27.7) 279 (37.3) 215 (28.7) 34 (4.5) OTHER 10 (5.9) 64 (37.6) 52 (30.6) 39 (22.9) 5 (2.9) STATEWIDE 32 (1.4) 578 (24.5) 870 (36.8) 782 (33.1) 102 (4.3)

QCOR Annual Report 2017 Page CS 11 21.3 Aboriginal and Torres Strait Islander status Ethnicity is an important determinant of health with a known impact on the development of cardiovascular disease. It is recognised that the Aboriginal and Torres Strait Islander population have a higher incidence and prevalence of coronary artery disease than other ethnicities.11 Overall, the proportion of identified Aboriginal and Torres Strait Islander patients undergoing cardiac surgery was 7.1%. This proportion is larger than the estimated 4.0% of the overall Queensland population that Aboriginal and Torres Strait Islander people account for.3

ANY CABG

CABG + VALVE

OTHER

VALVE

STATEWIDE

Cardiac Surgery Cardiac 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10%

Figure 10: Proportion of cases by identified Aboriginal and Torres Strait Islander status and surgery category

Page CS 12 QCOR Annual Report 2017 22 Risk factor profile

22.1 Smoking history Overall, 60% of patients had a history of tobacco use including 18% current smokers (defined as smoking within 30 days of the procedure) and 42% former smokers. The remaining 35% reported never having smoked and 5% had an unknown smoking history.

Current smoker Former smoker Never smoked Unknown

ANY CABG

CABG + VALVE

VALVE

OTHER Cardiac Surgery Cardiac STATEWIDE

0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50%

Figure 11: Proportion of cases by smoking status and surgery category

22.2 Diabetes The prevalence of diabetes was highest in the CABG group, with 35% of patients known to be diabetic.

ANY CABG

CABG + VALVE

VALVE

OTHER

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 12: Proportion of cases by diabetes status and surgery category

QCOR Annual Report 2017 Page CS 13 22.3 Hypertension Hypertension, defined as receiving antihypertensive medications at the time of surgery, was present in 69% of patients with considerable variation by surgery type (range 38% to 80%).

ANY CABG

CABG + VALVE

VALVE

OTHER

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 13: Proportion of cases by hypertension status and surgery category Cardiac Surgery Cardiac 22.4 Statin therapy Overall, 64% of patients were treated with statins for abnormal cholesterol at the time of surgery, ranging from 81% in the CABG category to 29% in the other surgery category. This does not account for statin treatment rates prior to admission or investigation for coronary artery disease. This metric will be the focus of an enhancement to data collection methods for future reporting.

ANY CABG

CABG + VALVE

VALVE

OTHER

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 14: Proportion of cases by statin therapy status and surgery category

22.5 Renal impairment 54% of all patients were identified as having impaired renal function (eGFR≤ 89 mL/min/1.73 m2) at the time of their surgery. Of these patients, the CABG and valve group had the highest incidence of renal impairment (68%).

ANY CABG

CABG + VALVE

VALVE

OTHER

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 15: Proportion of cases by renal impairment status and surgery category Page CS 14 QCOR Annual Report 2017 22.6 Severe renal dysfunction There were 2.7% of patients identified as having renal dysfunction (preoperative creatinine >200 μmol/L), ranging from 2% to 5% across surgery categories. This cut-off is used by the EuroSCORE for predicting risk.

ANY CABG

CABG + VALVE

VALVE

OTHER

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 16: Proportion of cases by severe renal dysfunction status and surgery category Cardiac Surgery Cardiac 22.7 Left ventricular function Almost a third (30%) of patients were classed as having an impaired left ventricular ejection fraction (LVEF), including 19% with mild LV dysfunction (LVEF between 40% to 50%), 7% with moderate LV dysfunction (LVEF between 30% to 39%) and 4% with severe LV dysfunction (LVEF less than 30%).

Mild Moderate Severe

ANY CABG

CABG + VALVE

VALVE

OTHER

STATEWIDE

0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50%

Figure 17: Proportion of cases by LV dysfunction category and surgery category

QCOR Annual Report 2017 Page CS 15 22.8 Summary of risk factors The development of coronary artery disease is dependent on a number of background variables and risk factors. Analysis of risk factors and surgical categories has found that there are a number of combinations of risk factors that have a greater representation in some categories thus reflecting the complex medical history of many patients.

Table 6: Summary of risk factors by surgery category

ANY CABG CABG + VALVE VALVE OTHER ALL n (%) n (%) n (%) n (%) n (%) Current smoker 274 (23.0) 35 (13.7) 97 (13.0) 18 (10.6) 424 (17.9) Former smoker 510 (42.8) 124 (48.6) 300 (40.1) 58 (34.1) 992 (42.0) Diabetes 417 (35.0) 78 (30.6) 121 (16.2) 19 (11.2) 635 (26.9) Hypertension 947 (79.5) 192 (75.3) 426 (57.0) 65 (38.2) 1,630 (69.0) Statin therapy 965 (81.0) 180 (70.6) 309 (41.3) 50 (29.4) 1,504 (63.6) eGFR ≤89 mL/min/1.73m2 621 (52.1) 173 (67.8) 416 (55.6) 75 (44.1) 1,285 (54.4)

Cardiac Surgery Cardiac Severe renal dysfunction 29 (2.4) 13 (5.1) 19 (2.5) 3 (1.8) 64 (2.7) LVEF 40%–50% 258 (21.7) 48 (18.8) 118 (15.8) 23 (13.5) 447 (18.9) LVEF 30%–39% 95 (8.0) 19 (7.5) 43 (5.7) 5 (2.9) 162 (6.9) LVEF <30% 51 (4.3) 17 (6.7) 14 (1.9) 20 (11.8) 102 (4.3) BMI ≥30 kg/m2 488 (41.0) 103 (40.4) 249 (33.3) 44 (25.9) 884 (37.4)

Table 7: Summary of combined risk factors by surgery category

ANY CABG CABG + VALVE VALVE OTHER ALL n (%) n (%) n (%) n (%) n (%) Hypertension + Statin therapy 804 (67.5) 148 (58.0) 251 (33.6) 35 (20.6) 1,238 (52.4) Current/former smoker + 622 (52.2) 121 (47.5) 238 (31.8) 33 (19.4) 1,014 (42.9) Hypertension Current/former smoker + 539 (45.3) 99 (38.8) 147 (19.7) 17 (10.0) 802 (33.9) Hypertension + Statin therapy

BMI ≥30 kg/m2 + Statin 397 (33.3) 74 (29.0) 143 (19.1) 16 (9.4) 630 (26.6) therapy Diabetes + Hypertension + 320 (26.9) 62 (24.3) 82 (11.0) 5 (2.9) 469 (19.8) Statin therapy Diabetes + eGFR ≤89mL 215 (18.1) 50 (19.6) 73 (9.8) 6 (3.5) 344 (14.6) min/1.73m2 Current/former smoker + BMI 155 (13.0) 29 (11.4) 34 (4.5) 4 (2.4) 222 (9.4) ≥30 kg/m2 + Diabetes BMI ≥30 kg/m2 + Diabetes 227 (19.1) 47 (18.4) 68 (9.1) 5 (2.9) 347 (14.7)

Page CS 16 QCOR Annual Report 2017 23 Care and treatment of patients

23.1 Admission status Elective, urgent or emergent status varied widely between the various categories of surgeries. The majority of CABG cases were performed as urgent cases, whilst emergencies were predominately CABG followed by aortic surgery, in particular correction of aortic dissection.

Elective Urgent Emergency Salvage

ANY CABG

CABG + VALVE

VALVE

OTHER Cardiac Surgery Cardiac STATEWIDE

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%

Figure 18: Proportion of cases by admission status and surgery category

Table 8: Proportion of cases by admission status and surgery category

Elective Urgent Emergency Salvage n (%) n (%) n (%) n (%) ANY CABG 433 (36.4) 702 (58.9) 54 (4.5) 2 (0.2) CABG + VALVE 163 (63.9) 87 (34.1) 5 (2.0) 0 (0.0) VALVE 577 (77.1) 139 (18.6) 31 (4.1) 1 (0.1) OTHER 59 (34.7) 24 (14.1) 86 (50.6) 1 (0.6) STATEWIDE 1,232 (52.1) 952 (40.3) 176 (7.4) 4 (0.2)

QCOR Annual Report 2017 Page CS 17 23.2 Day of surgery admission Day of surgery admission (DOSA) rates accounted for 14% of all elective cases, with minor variations observed across most surgery categories.

ANY CABG

CABG + VALVE

VALVE

OTHER

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 19: Proportion of elective cases for DOSA by surgery category Cardiac Surgery Cardiac Table 9: Proportion of DOSA cases by surgery category

Total elective cases DOSA cases n n (%) ANY CABG 433 66 (15.2) CABG + VALVE 163 17 (10.4) VALVE 577 79 (13.7) OTHER 59 6 (10.2) STATEWIDE 1,232 168 (13.6)

Page CS 18 QCOR Annual Report 2017 23.3 Coronary artery bypass grafts

23.3.1 Number of diseased vessels In total, 1,446 patients had a CABG procedure. The majority (91%) had multi-vessel disease. When CABG was performed in conjunction with a valve procedure, 68% of patients had multi-vessel disease compared to 96% when CABG was performed without a valve procedure.

Single vessel Multi-vessel

ANY CABG

CABG + VALVE

VALVE

OTHER

STATEWIDE Cardiac Surgery Cardiac 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%

Excludes missing data/not applicable (total n=6) Figure 20: Number of diseased vessels

Table 10: Number of diseased vessels

Single vessel Multi-vessel ALL* n (%) n (%) n (%) ANY CABG 49 (4.1) 1,138 (95.9) 1,187 (100.0) CABG + VALVE 81 (32.0) 172 (68.0) 253 (100.0) STATEWIDE 130 (9.0) 1,310 (91.0) 1,440 (100.0) * Excludes missing data/not applicable (total n=6)

23.3.2 Mean number of grafts Overall the mean number of grafts performed was 2.7. In multi vessel CABG, the mean number of grafts was 2.9.

Table 11: Mean number of grafts by number of diseased vessels

Single vessel Multi vessel Multi vessel ALL* (mean) (mean) (median) (mean) ANY CABG 1.3 3.0 3 2.9 CABG + VALVE 1.1 2.4 2 2.0 STATEWIDE 1.2 2.9 3 2.7 * Excludes missing data/not applicable (total n=6)

QCOR Annual Report 2017 Page CS 19 23.3.3 Conduits used In CABG, including surgeries involving valvular intervention, the most common form of revascularisation required the use of a combination of an arterial and vein graft (72%). Total arterial revascularisation occurred in 13% of cases.

Artery + Vein Artery only Vein only

Single vessel

Multi-vessel

STATEWIDE

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%

Excludes missing data/not applicable (total n=7) Figure 21: Proportion of diseased vessels by conduits used Cardiac Surgery Cardiac

Table 12: Conduits used by number of diseased vessels

Artery + Vein Artery only Vein only n (%) n (%) n (%) Single vessel 14 (10.9) 62 (48.1) 53 (41.1) Multi-vessel 1,027 (78.4) 132 (10.1) 151 (11.5) STATEWIDE 1,041 (72.3) 194 (13.5) 204 (14.2) Excludes missing data/not applicable (total n=7)

23.3.4 Off pump CABG Approximately 2% of isolated CABG were performed without cardiopulmonary bypass.

Table 13: Off pump CABG

Total Off pump n n (%) Isolated CABG 1,147 22 (1.9)

23.3.5 Y or T grafts Overall, 4% of CABGs included a Y or T graft.

Table 14: Y or T graft used by procedure category

Total Y or T graft n n (%) ANY CABG 1,191 57 (4.8) CABG + VALVE 255 6 (2.4) STATEWIDE 1,446 63 (4.4)

Page CS 20 QCOR Annual Report 2017 23.4 Aortic surgery There was a total of 209 cases that included a procedure involving the aorta (not including procedures conducted on the aortic valve). Most aortic surgery procedures included replacement of the ascending aorta in isolation (68%), while surgery to replace both the ascending aorta and aortic arch accounted for 15% of cases. Aortic aneurysm was the primary reason for aortic surgery (52%).

Table 15: Aortic surgery by procedure type

Aortic surgery type n (%) Replacement 183 (87.6) Ascending 142 (67.9) Ascending + Arch 32 (15.3) Arch 4 (1.9) Ascending + Arch + Descending 2 (1.0) Descending + Thoracoabdominal 1 (0.5) Cardiac Surgery Cardiac Descending 1 (0.5) Arch + Thoracic 1 (0.5) Aortoplasty 24 (11.5) Patch repair 19 (9.1) Direct aortoplasty 3 (1.4) Endarterectomy 1 (0.5) Patch repair + Endarterectomy 1 (0.5) Aortoplasty and Replacement 2 (1.0) Patch repair + Ascending + Arch 2 (1.0) STATEWIDE 209 (100.0)

23.4.1 Aortic pathology

Table 16: Aortic surgery cases by pathology type

Aortic pathology type n (%) Aortic aneurysm 108 (51.7) Aortic dissection (≤2 weeks) 45 (21.5) Other 28 (13.4) Calcification 18 (8.6) Aortic dissection (>2 weeks) 8 (3.8) Traumatic transection 2 (1.0) STATEWIDE 209 (100.0)

QCOR Annual Report 2017 Page CS 21 23.5 Valve surgery In participating sites, valve surgery was performed in 1,003 cases during 2017. The aortic valve was the most commonly operated on valve either with or without other valves (67%). Mitral valve surgery accounted for the next most common valvular surgery.

Aortic

Mitral

Aortic and mitral

Mitral and triscuspid

Tricuspid

Aortic, mitral and tricuspid

Aortic and pulmonary

Aortic, mitral and pulmonary Cardiac Surgery Cardiac Tricuspid and pulmonary

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 22: Proportion of valve surgery cases by valve

Table 17: Valve surgery cases by valve

Type of valve surgery n (%) Aortic 618 (61.6) Mitral 251 (25.0) Aortic and mitral 38 (3.8) Mitral and tricuspid 37 (3.7) Tricuspid 30 (3.0) Pulmonary 11 (1.1) Aortic and tricuspid 7 (0.7) Aortic, mitral and tricuspid 6 (0.6) Tricuspid and pulmonary 2 (0.2) Aortic and pulmonary 2 (0.2) Aortic, mitral and pulmonary 1 (0.1) STATEWIDE 1,003 (100.0)

Page CS 22 QCOR Annual Report 2017 22.5.1 Valve pathology The most common valve pathology across all valve types was calcific (32%), and accounted for almost half (49%) of all aortic valve procedures.

Table 18: Valve pathology by valve type

Aortic Mitral Tricuspid Pulmonary ALL n (%) n (%) n (%) n (%) n (%) Calcific 326 (48.5) 27 (8.1) - - 353 (32.0) Myxomatous 54 (8.0) 119 (35.7) 10 (12.2) 2 (12.5) 185 (16.8) Congenital 103 (15.3) 6 (1.8) 4 (4.9) 6 (37.5) 119 (10.8) Infection 52 (7.7) 44 (13.2) 13 (15.9) 2 (12.5) 111 (10.1) Degenerative 46 (6.8) 35 (10.5) 24 (29.3) - 105 (9.5) Rheumatic 16 (2.4) 47 (14.1) 11 (13.4) - 74 (6.7) Other 32 (4.8) 28 (8.4) 15 (18.3) 1 (6.3) 76 (6.9) Prosthesis failure 22 (3.3) 13 (3.9) - 1 (6.3) 36 (3.3) Ischaemic - 14 (4.2) - - 14 (1.3) Cardiac Surgery Cardiac Dissection 12 (1.8) - - - 12 (1.1) Annuloaortic ectasia 8 (1.2) - - - 8 (0.7) Functional - - 4 (4.9) - 4 (0.4) Failed prior repair - - 1 (1.2) 3 (18.8) 4 (0.4) Iatrogenic 1 (0.1) - - - 1 (0.1) Inspection only - - - 1 (6.3) 1 (0.1) STATEWIDE 672 (100.0) 333 (100.0) 82 (100.0) 16 (100.0) 1,103 (100.0)

QCOR Annual Report 2017 Page CS 23 23.5.2 Types of valve surgery The majority of valve surgery cases involved aortic valve intervention (67%). The most common aortic valve procedure was replacement surgery (98%) with remainder involving valve repair. Similarly for the mitral valve, replacement was more frequent than repair (55% vs 44%).

Aortic* Mitral Tricuspid

Repair

Replacement

0% 20% 40% 60% 80% 100%0% 20% 40% 60% 80% 100%0% 20% 40% 60% 80% 100%

* Aortic replacement category includes transcatheter aortic valve replacement cases Figure 23: Valve surgery category by valve

Table 19: Valve surgery category by valve type Cardiac Surgery Cardiac Surgery category Aortic Mitral Tricuspid Pulmonary ALL n (%) n (%) n (%) n (%) n (%) Repair 12 (1.8) 148 (44.4) 64 (78.0) 0 (0.0) 224 (20.3) Replacement 660 (98.2) 184 (55.3) 18 (22.0) 15 (93.8) 877 (79.5) Inspection only 0 (0.0) 1 (0.3) 0 (0.0) 1 (6.3) 2 (0.2) STATEWIDE 672 (100.0) 333 (100.0) 82 (100.0) 16 (100.0) 1,103 (100.0)

23.5.3 Valve repair surgery The most common form of valve repair surgery was repair/reconstruction with annuloplasty (77%), followed then by annuloplasty only (9%). Mitral valve repair/reconstruction with annuloplasty was the most common individual valve repair surgery comprising 57% of overall valve repair surgery. It has been identified that there is an opportunity to improve data collection in cases involving mitral and tricuspid valve repair as the definitions relating to this surgery and the reporting application may be ambiguous. A future focus for this report will be the enhancement of data quality relating to these elements.

Table 20: Valve repair surgery by valve type

Aortic Mitral Tricuspid Pulmonary ALL n (%) n (%) n (%) n (%) n (%) Repair/reconstruction with annuloplasty - 128 (86.5) 44 (68.8) - 172 (76.8) Annuloplasty only - 6 (4.1) 13 (20.3) - 19 (8.5) Repair/reconstruction without annuloplasty - 11 (7.4) 5 (7.8) - 16 (7.1) Root reconstruction with valve sparing 8 (66.7) - - - 8 (3.6) Resuspension of aortic valve 3 (25.0) - - - 3 (1.3) Tumour tissue removal - 1 (0.7) 1 (1.6) - 2 (0.9) Decalcification of valve only 1 (8.3) 1 (0.7) - - 2 (0.9) Commissurotomy with annuloplasty ring - 1 (0.7) - - 1 (0.4) Thrombus removal - - 1 (1.6) - 1 (0.4) STATEWIDE 12 (100.0) 148 (100.0) 64 (100.0) - 224 (100.0)

Page CS 24 QCOR Annual Report 2017 23.5.4 Valve replacement surgery Aortic valve replacement accounted for the majority of valve replacement surgeries (75%). The reported number of TAVR cases reflects those in which a cardiothoracic surgeon was present during the procedure and does not represent the total number of these surgeries performed throughout Queensland in 2017. Further detail regarding TAVR procedures are outlined in the structural heart disease supplement of the interventional cardiology chapter of this Annual Report.

Table 21: Valve replacement surgery by valve type

Surgery type Aortic Mitral Tricuspid Pulmonary ALL n (%) n (%) n (%) n (%) n (%) Replacement 540 (81.8) 184 (100.0) 18 (100.0) 15 (100.0) 757 (86.3) Root reconstruction with valve conduit 79 (12.0) - - - 79 (9.0) TAVR 40 (6.1) - - - 40 (4.6) Pulmonary autograft aortic root replacement 1 (0.2) - - - 1 (0.1) STATEWIDE 660 (100.0) 184 (100.0) 18 (100.0) 15 (100.0) 877 (100.0) Cardiac Surgery Cardiac The most common form of valve prostheses used across all valve types were biological (76%). Mechanical prostheses were used in 31% of cases with a greater proportion represented in mitral valve replacement surgeries. Bovine pericardial aortic valve prostheses accounted for the largest proportion of all valves used (34%).

Biological Mechanical Other*

Aortic

Mitral

Tricuspid

Pulmonary

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%

* Includes homograft/allograft and autograft Figure 24: Proportion of valve replacements by valve prosthesis category and valve type

Table 22: Types of valve prosthesis by valve type

Prosthesis type Aortic* Mitral Tricuspid Pulmonary ALL n (%) n (%) n (%) n (%) n (%) Biological – bovine pericardial 297 (45.0) 54 (29.3) 4 (22.2) 11 (73.3) 366 (41.7) Biological – porcine 226 (34.2) 63 (34.2) 13 (72.2) 0 (0.0) 302 (34.4) Mechanical 134 (20.3) 67 (36.4) 1 (5.6) 0 (0.0) 201 (22.9) Homograft/allograft 2 (0.3) 0 (0.0) 0 (0.0) 2 (13.3) 4 (0.5) Autograft 1 (0.2) 0 (0.0) 0 (0.0) 2 (13.3) 3 (0.3) STATEWIDE 660 (100.0) 184 (100.0) 18 (100.0) 15 (100.0) 877 (100.0)

QCOR Annual Report 2017 Page CS 25 23.6 Other cardiac surgery The most common forms of other cardiac surgery were left atrial appendage closure (19%), followed by bilateral sequential single lung transplantation (14%).

Table 23: Other cardiac procedures

Procedure n (%) Left atrial appendage closure 55 (19.2) Other reason 44 (15.4) BSSLTX* 40 (14.0) Atrial septal defect repair 39 (13.6) Atrial arrhythmia surgery 26 (9.1) LVOT‡ myectomy 17 (5.9) Cardiac tumour surgery 12 (4.2) Other congenital repair 9 (3.1) Cardiac transplant 8 (2.8)

Cardiac Surgery Cardiac Pulmonary thrombo-endarterectomy 7 (2.4) Pericardiectomy 6 (2.1) Ventricular septal defect repair 6 (2.1) LV rupture repair 4 (1.4) PFO† closure 3 (1.0) Cardiopulmonary transplant 3 (1.0) Permanent LV epicardial lead 3 (1.0) Lung transplant 2 (0.7) Trauma 2 (0.7) STATEWIDE 286 (100.0) * Bilateral sequential single lung transplantation † Patent foramen ovale ‡ Left ventricular outflow tract

Page CS 26 QCOR Annual Report 2017 23.7 Blood product usage The majority of surgeries did not require blood product transfusion. As the urgency of operations increased, a stepwise greater requirement for red blood cells (RBC) and non-red blood cells (NRBC) was observed. Emergency and salvage cases had much higher transfusion rates.

Blood products used No blood products used

Elective

Urgent

Emergency

Salvage

STATEWIDE

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% Cardiac Surgery Cardiac Figure 25: Blood product usage by admission status

Table 24: Blood product usage by admission status

Both RBC and NRBC RBC NRBC No blood products n (%) n (%) n (%) n (%) Elective 131 (10.6) 144 (11.7) 94 (7.6) 863 (70.0) Urgent 149 (15.7) 182 (19.1) 74 (7.8) 547 (57.5) Emergency 87 (49.4) 26 (14.8) 23 (13.1) 40 (22.7) Salvage 3 (75.0) - - 1 (25.0) STATEWIDE 370 (15.7) 352 (14.9) 191 (8.1) 1,451 (61.4)

QCOR Annual Report 2017 Page CS 27 24 Outcomes

There are two aspects of outcomes analysis for procedural related specialties: the risk of complications from procedures, and key targets for optimal procedural performance. This report focuses on the risk of complications from procedures and compared the aggregated outcomes of the 4 adult cardiac surgical units against calculated risk scores.

24.1 Risk prediction models Risk adjustment algorithms are a means of estimating the likelihood of an outcome based on patient and clinical factors known at the time of surgery. Risk scores in cardiac surgery are developed on large patient cohorts and are usually relevant for a particular period in time and in a particular geographic area. In developing the scores, patient and surgical factors are analysed, and factors that are identified as statistically associated with the level of risk of surgery are identified. This statistical analysis allows the adjustment of risk for patients with certain characteristics, who are undergoing particular types of surgery. The most common outcome evaluated using these risk adjustment algorithms is death after an operation, however, the Society of Thoracic Surgeons (STS) has also developed a range of algorithms predictive of the risk Cardiac Surgery Cardiac of complications (morbidity) after an operation. The risk models used in evaluating the 2017 clinical outcomes for cardiac surgical cases are: • EuroSCORE • ANZSCTS General Score • AusSCORE • STS Score (mortality and morbidity)

While EuroSCORE12 and the ANZSCTS General Score13 can be applied to evaluate deaths for all types of cardiac surgical cases, the AusSCORE model14 has been developed to be applied to deaths in CABG cases only. As previously noted, the STS scores provide an estimate of the risk for mortality as well as a range of morbidities, however, these are specific to limited subgroups of cardiac surgery procedures (CABG model: isolated coronary artery bypass only.15 Valve model: isolated aortic valve replacement, isolated mitral valve replacement or isolated mitral valve repair.16 Valve + CABG model: CABG plus one of aortic valve replacement, mitral valve replacement or isolated repair.)17 Although EuroSCORE (published 1999) has, with the passage of time, become less calibrated to contemporary outcomes in cardiac surgery, it retains its ability to discriminate risk. In this evaluation it has been retained to provide a benchmark for comparison to historical performance and as such provides a useful reminder of how far practice has improved in the past 20 years. Although EuroSCORE II has been developed to address the calibration issue of the original model, it was not used in this evaluation as the full suite of factors required for the risk score are not universally collected in the QCOR dataset. Only one site calculates this score routinely as a separate data point. The database will be modified to include the data required for EuroSCORE II so that it can be calculated in future reports. The graphs provided in the following sections compare the actual observed rates of mortality and morbidities to that predicted using each risk model. However, when interpreting the messages provided by this analysis it is important to understand that there is more to performance in surgery than simply the decisions made by the surgeon in before, during and after the patient enters the operating theatre. Several aspects of the patient’s entire journey to disease and through treatment and recovery may combine to influence the outcome of surgery. When reviewing the document outcomes it is important to remember that there are five important drivers that may lead to observed differences between the predicted and observed results: 1. Data: Were there any issues with the quality of data? Were events documented accurately using uniformly applied definitions? 2. Case mix: Were there factors inherent in the patient that were not adequate dealt with in the risk adjustment? 3. Environment and resources: Did a lack of resources or environmental issues contribute to the variation? 4. Process of care: Was there a breakdown in the care process? 5. Carer: Were there individual surgeon decisions or technical issues that contributed to the outcome? In preparing the analysis presented here, significant effort has been expended to ensure the data is of an acceptable quality both in terms of completeness and uniformity of definition.

Page CS 28 QCOR Annual Report 2017 24.1.1 Mortality The most commonly evaluated outcome (reflecting its significance) in a risk-adjusted analysis is death within 30 days of surgery. In this evaluation, the mortality rate of patients undergoing cardiac surgery in 2017 has been evaluated using the previously described risk models. As the STS provide models that are applicable only to defined subgroups of procedures, it is important to note that the STS models have been used to evaluate outcomes only in the range of cases meeting the inclusion criteria. The Total outcome chart for the STS models has been derived by pooling all results for the CABG Only, Valve Only and CABG + Valve models. Likewise, the AusSCORE model has been used for CABG only cases and is presented side-by-side with the other risk score predictions for CABG only cases. In all evaluations, the observed mortality rate (shown as a red diamond) is either within or significantly better than expected. Cardiac Surgery Cardiac Legend: Observed Predicted (95% confidence interval)

Figure 26: EuroSCORE Figure 27: ANZSCTS General Score

Figure 28: STS (death) Figure 29: CABG

QCOR Annual Report 2017 Page CS 29 24.1.2 Morbidity Apart from death, patients undergoing cardiac surgery are at risk of experiencing a range of significant morbidities. The STS risk models provide an estimate of the level risk for a patient of experiencing these morbidities. These models have been applied to the defined subgroups using the defined inclusion criteria. The aggregated morbidities chart (Figure 34) represents the observed rate of cases involving at least one of the five morbidities. For 2017, most comparisons between the observed event rate and the rate predicted using the respective risk scores, demonstrate that outcomes are within expectation. The exception is deep sternal wound infection (DSWI) in CABG cases where the rate appears to be significantly higher. This data is not directly comparable with 2016 because that dataset was from three units, whereas 2017 included four units, and the significant variations in caseload with the addition of the fourth unit means that statistical comparisons from year to year cannot be made. Nevertheless, the data again demonstrates a higher observed rate than expected from the STS risk score calculator. Cardiac Surgery Cardiac Legend: Observed Predicted (95% confidence interval)

Figure 30: CVA Figure 31: Renal failure

Figure 32: Ventilation >24 hours Figure 33: Reoperation

Page CS 30 QCOR Annual Report 2017 The 2016 rate is discussed in the next section. With respect the 2017 rate, we will audit two aspects: DSWI cases, and the reopen rate for CABG, to first ascertain whether these two markers are indeed linked, and secondly to ensure that the rates are reliable. Secondly, we will ask the ANZSCTS national database to make comment on the individual units when compared to a national standard, as 2017 is the first year in which the ANZSCTS national database also includes data from all public Queensland units. The ANZSCTS national database performs analysis of individual unit performance and identifies outliers as part of that process. Thus their input will help clarify whether the observed statewide rate is significant or not. Overall, when evaluated using the STS morbidity models, the rate of morbidity remains within a statistically predicted rate. Cardiac Surgery Cardiac Legend: Observed No event observed Predicted (95% confidence interval)

Figure 34: Deep sternal wound infection Figure 35: Major morbidity

QCOR Annual Report 2017 Page CS 31 24.1.3 Measures of process The following charts evaluate the length of stay (LOS) of patients compared with that predicted by the STS score. LOS less than 6 days is a measure of process that allows for elective weekly booking procedures. LOS greater than 14 days excludes the patients who may stay several days after the 6 day cut off for minor reasons, but instead are on a prolonged recovery pathway. This comparison suggests that the proportion of cases staying less than 6 days is better than expected, that is, more patients that are discharged before 6 days than predicted. Additionally, the proportion of patients who stay longer than 14 days is greater than expected, perhaps indicating that those who cannot return home immediately post surgery are instead facing delays being transferred to other institutions within the health service, such as rehabilitation, regional hospitals or nursing homes.

Legend: Observed Predicted (95% confidence interval) Cardiac Surgery Cardiac

Figure 36: LOS <6 days Figure 37: LOS >14 days

Page CS 32 QCOR Annual Report 2017 24.1.4 Failure to rescue One explanation for improved outcomes in high volume centres is that patients who suffer a complication are better treated, and hence are rescued from further progression of complications that can lead to death. Failure to rescue is a measure calculated from the risk of adverse events and the risk of death in combination, based on the assumption that an adverse event can result in death if not appropriately rescued by the hospital processes. Based on this analysis, the failure to rescue observed rate for CABG cases (shown as a red diamond) is statistically better than predicted and the rate for valve, and combined CABG and valve cases is within the expected range. It is reasonable to conclude that hospital processes to deal with adverse events are functioning better than expected.

Legend: Observed Predicted (95% confidence interval) Cardiac Surgery Cardiac

Figure 38: Failure to rescue

QCOR Annual Report 2017 Page CS 33 24.1.5 DSWI 2016 The 2016 report identified an observed rate of deep sternal wound infection (DSWI) that was higher than expected from the STS risk prediction model. The committee asked each unit that contributed to the 2016 report to audit the cases identified as DSWI. The definition of DSWI according to the STS model is a return to theatre for debridement or reopening of the mediastinum, positive blood cultures unless on antibiotics, and prolonged treatment with antibiotics. Auditing the data identified patients who were identified as having DSWI in the complications, but were either coded more than once or did not actually meet all three STS criteria. This revised the observed rate down to within the confidence interval around the STS predicted rate. The 2016 ANZSCTS National Annual Report18 identifies rates of DSWI from between 0.2% to 3.5% depending on the type of procedure, on the presence or absence of diabetes or renal dysfunction and the increasing age of the patient. The average overall rate was 1.6% for 2016, and 1.0% to 1.5% for 2012–2015 depending on the procedure. In our analysis of the 2016 QCOR data, the STS model predicted an overall rate of 0.3%. This rate is much lower than the rate observed across Australia, and hence our data, though in line with the national rate, raised a statistical flag. It is reasonable thus to assume, as researchers from the UK have done, that there is a fixed relationship between the STS prediction model and the observed rate in the 2016 data.19 They found a relationship of approximately four times, which is similar to the relationship between the

Cardiac Surgery Cardiac predicted and observed rates in our 2016 data. As in the aforementioned discussion about the 2017 data, the 2016 data is not comparable. Thus, we will approach 2017 with the same approach as 2016, with assistance from the ANZSCTS database, and make further comment on the ongoing presence of a fixed relationship in the next report.

Legend: Observed No event observed Predicted (95% confidence interval)

Figure 39: Comparison of 2016 deep sternal wound infection rates, pre vs. post audit

Page CS 34 QCOR Annual Report 2017 25 Conclusions 26 Recommendations

This report again demonstrates that cardiac surgery The detail captured in the cardiac surgical database is performed with high quality results and safety is being refined with changes planed for valve in Queensland. We can now conclude this across repair, microbiology and aetiology of endocarditis. all public sites in Queensland because of the The review process ensures that there is consistent involvement of all public units in the database. The categorisation of data across sites, allowing for expected rates of mortality and morbidity derived comparision and analysis of the data statewide. from well established and widely used risk scores are The endocarditis supplement highlighted that this much higher than we see in our database, reflecting disease as a distinct entity needs investigation by that cardiac surgery in Queensland is performed at the network. The surgical series of endocarditis is the higher than expected levels of safety. numerator on the denominator of medically treated We see from this report that the most likely endocarditis. The high mortality risk of prosthetic description of a patient undergoing cardiac surgery valve endocarditis highlights that the aetiology of in Queensland is a 70-year-old male with obesity, endocarditis needs to be tracked and public health hypertension who used to smoke and has some measures instituted to modify an patterns that

degree of renal dysfunction. There are patients who emerge. It is a high risk and resource intense disease Surgery Cardiac do not fit this description, with both the very young when surgery is needed. and the very old undergoing surgery, as well as those The current cardiac surgery database data elements of normal weight, normal renal function and those do not encompass all required fields to enable who have never smoked. However, focusing on the EuroSCORE II modelling and calculation. With these most common patient, the impact of obesity stands data elements included, more risk calculation and out as an issue requiring further investigation. Some comparison can be undertaken. These changes are a research reports that surgery is safer for those who current work in progress and will be implemented for are overweight compared to those who are normal use in the 2019 calendar year. weight, while anecdotally, those with morbid obesity may not have higher risks of death, but consume The utility of the cardiac surgery database within greater resources post surgery. Thus, the next report QCOR is that the use of surgery within cardiac will look deeper into the issue of obesity in cardiac disease can be analysed as part of the entire cardiac surgery in Queensland. disease network, for example, the rates of coronary surgery compared to PCI, or the rates of TAVR The fact that patients are most likely to be former compared to AVR, which is part of the emphasis on smokers is a reflection on the benefits of public disease focused reporting, rather than service level health programs that have reduced smoking rates. analysis. Integrated analysis and reporting is part of To reduce the rates of smoking, the proportion of the work ahead for QCOR. people who identify as “former smokers” needs to increase, so it is gratifying to see that most patients are in this group. There was a day when most patients were “current smokers”. The combined risk factors data is in its infancy. It may be that trends appear over time allowing for comments to be made. At present, one can see that most patients have a combination of risk factors. Work needs to be done to improve the database to identify the degree of patients who are not treated for their risk factors prior to admission to hospital, identifying primary care opportunities to improve cardiac disease. The role and limitations of risk scores are again demonstrated, particularly when risk scores are not derived from similar contemporaneous populations. Nevertheless, for a project that covers four sites, comparison to risk scores rather than to each other, is a reasonable process, and will evolve with each iteration of this report.

QCOR Annual Report 2017 Page CS 35 27 Supplement: Infective endocarditis

Infective endocarditis is a condition in which infection takes up residence in the structures of the heart, resulting in destruction and dysfunction. As this is a surgical database, the cases analysed here are those patients who have reached a severity of infection that requires surgery to attempt to remove the infected tissue and to repair the destroyed structures, restoring function. These operations range in degrees of technical challenge and risk because the extent of infection within the heart can vary, the virulence of the infecting organism ranges from slow growing, to rapidly destructive, and the degree to which the rest of the body is infected and affected as an entire system is different for each patient. The committee felt that more detailed analysis of this problem may enlighten us on strategies to manage this condition, and at the very least identify gaps in the database that are relevant to this clinical condition. The distinction between active and treated endocarditis deserves clarification. Treated endocarditis is a condition in which the infection has been controlled and sterilised with antibiotics and the patient is now undergoing surgery for residual cardiac dysfunction. Active endocarditis is the condition in which bacterial infection is active at the time of surgery, and surgery is for heart failure, valve dysfunction, risk of embolisation or to control the infection in addition to antibiotics. To clarify, the distinction between “active” Cardiac Surgery Cardiac and “treated” does not imply that active infections are not treated with antibiotics at the time of surgery.

Page CS 36 QCOR Annual Report 2017 Cardiac Surgery Cardiac

Figure 1: Infective endocarditis cases by residential postcode

QCOR Annual Report 2017 Page CS 37 27.1 Patient characteristics More than three-quarters of infective endocarditis patients were male (79%), with a greater median age of 56 years for males than 46 years for females. The proportionally largest group of patients however, were males aged below 40 years of age (17%).

20%

10% Cardiac Surgery Cardiac 0% < 40 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84

Figure 2: Infective endocarditis cases by age category

Table 1: Infective endocarditis cases by gender and age category

Age Male Female ALL n (%) n (%) n (%) <40 17 (16.7) 2 (2.0) 19 (18.6) 40–44 8 (7.8) 6 (5.9) 14 (13.7) 45–49 4 (3.9) 5 (4.9) 9 (8.8) 50–54 9 (8.8) - 9 (8.8) 55–59 8 (7.8) - 8 (7.8) 60–64 6 (5.9) 3 (2.9) 9 (8.8) 65–69 7 (6.9) 1 (1.0) 8 (7.8) 70–74 13 (12.7) 4 (3.9) 17 (16.7) 75–79 3 (2.9) 1 (1.0) 4 (3.9) 80–84 5 (4.9) - 5 (4.9) ALL 80 (78.4) 22 (21.6) 102 (100.0)

Page CS 38 QCOR Annual Report 2017 27.2 Care and treatment of infective endocarditis patients The majority of patients undergoing surgical treatment for infective endocarditis had a valve procedure only (86%). 12% also underwent coronary bypass surgery with these two groups accounting for the vast majority of cases (98%).

CABG

CABG + VALVE

VALVE

OTHER

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 3: Infective endocarditis cases by surgery category

Table 2: Infective endocarditis cases by surgery category Surgery Cardiac

n (%) CABG 1 (1.0) CABG + VALVE 12 (11.8) VALVE 88 (86.3) OTHER 1 (1.0) ALL 102 (100.0)

QCOR Annual Report 2017 Page CS 39 Aortic valve endocarditis necessitating intervention was the most commonly performed surgery either with or without other valves (53% vs 40%). Aortic and mitral valve surgery was the most commonly performed multiple valve operation accounting for 10% of all cases. In total, 18% of surgeries for endocarditis involved intervention to multiple valves.

Aortic

Mitral

Tricuspid

Aortic and mitral

Mitral and triscuspid

Pulmonary

Aortic, mitral and tricuspid

Aortic, mitral and pulmonary

0% 10% 20% 30% 40% 50% Cardiac Surgery Cardiac

Figure 4: Infective endocarditis cases by type of valve

Table 3: Infective endocarditis valve surgery cases by type of valve

Valve type n (%) Aortic 40 (40.0) Mitral 32 (32.0) Tricuspid 10 (10.0) Aortic and mitral 10 (10.0) Mitral and tricuspid 3 (3.0) Aortic, mitral and tricuspid 2 (2.0) Pulmonary 2 (2.0) Aortic, mitral and pulmonary 1 (1.0) ALL 100 (100.0)

Table 4: Valve surgery procedures by valve type

Procedure type Aortic Mitral Tricuspid Pulmonary ALL n (%) n (%) n (%) n (%) n (%) Repair 1 (1.9) 14 (29.2) 7 (46.7) 0 (0.0) 22 (18.5) Replacement 52 (98.1) 34 (70.8) 8 (53.3) 2 (66.7) 96 (80.7) Inspection only 0 (0.0) 0 (0.0) 0 (0.0) 1 (33.3) 1 (0.8) ALL 53 (100.0) 48 (100.0) 15 (100.0) 3 (100.0) 119 (100.0)

Page CS 40 QCOR Annual Report 2017 27.3 Comorbidities 27.4 Microbiology Heart failure is a frequent clinical complication of 74 cases were classified as involving an active infective endocarditis and a very common surgical infection. Where clinical detail was available, the indication.20 The 2017 cohort included 22% patients most common organism was methicillin-sensitive with congestive heart failure at the time of operation. Staphylococcus aureus (MSSA) which accounted for Of these patients, 82% were defined as NYHA Class 42%. III or above. Overall, 21% of patients had some Of these 72 analysed active cases, 67% were native degree of left ventricular systolic dysfunction. valve endocarditis with the remainder involving The analysis was not able to determine the subset valvular prostheses. Detail regarding microbiology of patients who are current or reformed self- investigations were obtained by utilising other administered intravenous drug users (IVDU) due to applications, revealing a possible enhancement for insufficient data capture. future data collections. Further to this, the aetiology of infection is a useful data element to capture, Table 5: Selected comorbidities for patients further assisting in analyses and identification of undergoing valve intervention for infective trends in patient presentation. endocarditis

Table 6: Infective endocarditis cases by infection Surgery Cardiac Comorbidity n (%) status Cardiogenic shock 6 (5.9) Arrhythmia 28 (27.5) Status n (%) Atrial 26 (25.5) Active 74 (72.5) Heart block 1 (1.0) Treated 28 (27.5) Ventricular 1 (1.0) Total 102 (100.0) Inotrope requirement 3 (2.9) Table 7: Active infective endocarditis cases by Diabetes 20 (19.6) organism type Renal failure* 54 (52.9) Severe renal dysfunction† 5 (4.9) Organism n (%) Cerebrovascular accident 19 (18.6) MSSA 30 (41.7) Intravenous drug use‡ N/A Streptococcus 16 (22.2) Current N/A Enterococcus 10 (13.9) Previous N/A Other 10 (13.9) Congestive heart failure 22 (21.6) Staphylococcus (other) 6 (8.3) NYHA Class I 1 (4.5) Total 72 (100.0) NYHA Class II 3 (13.7) Excludes missing data (n=2) NYHA Class III 11 (50.0) NYHA Class IV 7 (31.8) Table 8: Active infective endocarditis cases by Left ventricular systolic dysfunction 22 (21.6) native versus prosthetic valve Mild (LVEF 40–50%) 16 (15.7) Status n (%) Moderate (LVEF 30–39%) 4 (3.9) Native 48 (66.7) Severe (LVEF <30) 2 (2.0) Prosthetic 24 (33.3) 2 * eGFG ≤89mL/min/1.73m Total 72 (100.0) † Pre operative creatinine >200µmol Excludes missing data (n=2) ‡ Insufficient data for analysis

QCOR Annual Report 2017 Page CS 41 27.5 Patient outcomes An unadjusted 30-day all-cause mortality rate of 9% was observed for all procedures. Prosthetic valve endocarditis carried a mortality rate of 25% compared to 8% of native valve infective endocarditis.

Table 9: All cause 30 day mortality by infection status and native versus prosthetic valve

Infection Total cases Mortality status (n) n (%) Active 74 9 (12.2) Native 49 4 (8.2) Prosthetic 25 5 (25.0) Treated 28 0 (0.0) ALL 102 9 (8.8) Cardiac Surgery Cardiac

Page CS 42 QCOR Annual Report 2017 27.6 Discussion There are several points to highlight from this data. As this is a surgically treated group of patients, and one indication for surgery is heart failure, the data reflects this with 82% of patients in significant heart failure, with NYHA heart failure III and above. The surgery performed often involves multiple valves (18%), again a marker of the severity of this condition. A particular subset of patients is those who have had cardiac surgery previously in which prosthetic material was used to either repair or replace a heart valve or other structures. This foreign material, essential to their first operation, can become infected later in life and require redo-surgery. Prosthetic valve endocarditis is a particularly challenging and high-risk situation when compared to native valve endocarditis, as demonstrated by the marked postoperative mortality in this group of 25%. To put this in context of the larger report and the community, there were close to a thousand valve operations in this year alone, in addition to all the patients in the community who have had valve operations in previous years, but only 28 operations for infected prosthetic valves. Thus, the risk of infecting a prosthetic valve is very low, but if that infection requires surgery, patients face a very high risk of death. As expected, patients with active infection at the time of surgery have a higher mortality than those who

have had their infections resolve with antibiotics prior to surgery. If the clinical situation indicates surgery is Surgery Cardiac needed prior to the infection being controlled, or indeed surgery is needed to control the infection because antibiotics alone are insufficient, then those patients have a more severe degree of infection and have a higher risk of death. Endocarditis is a bloodstream infection, in which there is an entry of bacteria into the bloodstream and carriage to the heart. Thus, it can be associated with other sites of infection, such as skin wounds or spinal infections, and with procedures, such as dental extractions or endoscopies in which bacteria can enter the bloodstream. It can also be associated with illicit intravenous drug use, making this condition relevant to legislators and public health policy. Inserting needles into veins requires clean techniques to minimise the risk of introducing bacteria into the bloodstream. Illicit administration is often inadequately clean, resulting in the introduction of bacteria, and is often a repeated behaviour, and hence repeated exposure. The registry team were able to identify at least 17 cases of documented IVDU, but whether this is remote or current is not clear, there can be no conclusions drawn about the range of aetiologies, nor where efforts can be focused, if at all. We can see from the analysis that there are two peaks of endocarditis. The young person under the age of 40, and those in the 70 to 75-year age group. Without data on the aetiology of endocarditis, we cannot explain this distribution. Again, amendments to the dataset will help explain this distribution with data.

QCOR Annual Report 2017 Page CS 43 Cardiac Surgery Cardiac

Page CS 44 QCOR Annual Report 2017 Electrophysiology and Pacing Audit Cardiac Surgery Cardiac

QCOR Annual Report 2017 Page EP 1 Electrophysiology and Pacing Electrophysiology

Page EP 2 QCOR Annual Report 2017 28 Message from the QCOR Electrophysiology and Pacing Committee Chair

The 2017 QCOR report expands to include for the first time data profiling demographics, activity and quality related to cardiac electrophysiology and pacing procedures in Queensland Health (QH) patients. This branch of cardiology practice has evolved to be responsible for, inter alia, significant and increasing rates of cardioverter/defibrillator (ICD) implants for prevention of sudden cardiac death, more complex time-consuming bi-ventricular pacing (otherwise known as cardiac resynchronisation therapy, CRT) procedures for heart failure patients, complex and increasingly numerous ablation procedures for atrial fibrillation (AF) and ventricular tachycardia (VT), an increasing demand for sophisticated pacemaker and ICD lead extraction techniques and deployment of technologies for remote monitoring of pacemaker and ICD patients. The advent of implantable loop recorders (ILRs) two decades ago provided the most valuable tool for diagnosis of the arrhythmic mechanism of unexplained syncope. Recently the introduction of an additional medical benefit schedule item number for ILR implant in the investigation of cryptogenic stroke has resulted in a very large increase in demand for these devices. In the background, increasing numbers of curative ablation interventions for (non-AF) supraventricular tachycardias continue to remove patients from QH care and increasing numbers of pacemaker interventions continue to enhance the lives of QH patients.

Increases in demand for and numbers of device and electrophysiological procedures will continue to be driven by an increasing, aging population with improved survival of other cardiovascular procedures, by adverse lifestyle trends and by technological advances. Authoritative activity and quality mapping is therefore mandatory for guidance of planning to address adequately these inescapable facts.

This initial data represents a snapshot of procedures in 2017; future reports will enable analysis of procedural success over time. The snapshot itself contains incomplete data by reason of logistics and some variation by

site in completeness of data, but these issues will resolve as future reports are compiled. and Pacing Electrophysiology

The scope of this report builds substantially on activity data published previously by the Electrophysiology Working Group21, which is developing clinical indicators for benchmarking of many aspects of procedures. Future analysis guided by these indicators will yield very important learnings about the journeys of QH patients who undergo procedures for heart rhythm disorders. Quality and performance metrics will naturally include assessment of waiting periods for procedures.

In the generation of this report, I wish to acknowledge the hard work of QCOR administrative staff, the indefatigable cardiac scientists who formulated the database, and the fortitude, confidence and cooperation of my clinical colleagues. Those qualities are traditional hallmarks of those who work in heart rhythm management.

Associate Professor John Hill Chair QCOR Electrophysiology and Pacing Committee

QCOR Annual Report 2017 Page EP 3 29 Key findings

This 2017 inaugural Queensland Electrophysiology and Pacing audit describes baseline demographics, risk factors, procedures performed and outcomes for an incomplete year of data collection. Key findings include: • Across Queensland, 7 public sites contributed data with staggered commencement dates for these data collections. • 3,134 electrophysiology and pacing cases were performed across the 7 participating public Queensland sites including 2,131 device procedures and 889 electrophysiology procedures. • The majority of all patients were aged over 60 years (57%) with a median age of 68 years. • The overall proportion of Aboriginal and Torres Strait Islander patients was 3.9%. • The vast majority of patients (70%) were classed as having an unhealthy body mass index (BMI) of greater than 30kg/m2. • The majority of procedures (52%) were classified as high urgency procedures that are clinically indicated within 30 days. • Outpatient procedures accounted for 54% of all cases. • 519 standard electrophysiology procedures were performed with a further 370 complex procedures undertaken utilising three-dimensional mapping technology and/or involving pulmonary vein isolation. • Radiofrequency ablation was employed in the vast majority of ablation cases (91%). Electrophysiology and Pacing Electrophysiology • Cavo-tricuspid isthmus (atrial flutter), pulmonary veins (atrial fibrillation) and atrioventricular node slow pathway ablations accounted for 80% of all ablation cases. • The most frequently ablated supraventricular arrhythmia was atrial fibrillation accounting for 28% of all cases with ventricular tachycardia making up 54% of all ventricular arrhythmia ablations. • The statewide aggregate for all device procedure complications was 4.6%, while all electrophysiology procedures had a 2.6% complication rate overall.

Page EP 4 QCOR Annual Report 2017 30 Participating sites

In 2017, there were eight public electrophysiology and pacing units spread across metropolitan and regional Queensland. Seven of these entered data directly into the Queensland Cardiac Outcomes Registry (QCOR) electrophysiology and pacing application. The eighth site, Gold Coast University Hospital began direct entry in 2018. Patients came from a wide geographical area, with the majority of patients residing on the Eastern Seaboard. Electrophysiology and Pacing Electrophysiology

Figure 1: Electrophysiology and pacing cases by residential postcode

Table 1: Participating sites

Site number Site name Date commenced Location Acronym 1 Cairns Hospital 5 April 2017 Regional CH 2 The Townsville Hospital 3 April 2017 Regional TTH 3 Mackay Base Hospital 26 April 2017 Regional MBH 4 Sunshine Coast University Hospital 6 July 2017 Regional SCUH 5 The Prince Charles Hospital 11 January 2017 Metropolitan TPCH 6 Royal Brisbane and Women’s Hospital 3 April 2017 Metropolitan RBWH 7 Princess Alexandra Hospital 9 January 2017 Metropolitan PAH Gold Coast University Hospital commenced direct data entry 29 January 2018 QCOR Annual Report 2017 Page EP 5 Figure 2: Cairns Hospital Figure 3: The Townsville Hospital Electrophysiology and Pacing Electrophysiology

Figure 4: Mackay Base Hospital Figure 5: Sunshine Coast University Hospital

Page EP 6 QCOR Annual Report 2017 Figure 6: The Prince Charles Hospital Figure 7: Royal Brisbane & Women’s Hospital Electrophysiology and Pacing Electrophysiology

Figure 8: Princess Alexandra Hospital

QCOR Annual Report 2017 Page EP 7 31 Case totals

31.1 Total cases In 2017, 3,134 electrophysiology and pacing procedures were documented using the Queensland Cardiac Outcomes Registry Electrophysiology and Pacing application. This number does not reflect the overall case totals as uptake of this new application was staggered across 2017.

Table 2: Total cases by category

Procedure combination Total cases Category n (%) Cardiac device procedure 2,112 (67.4) Device Cardiac device procedure + EP study 16 (0.5) Cardiac device procedure + drug challenge 2 (0.1) Cardiac device procedure + EP study + ablation 1 (<0.1) EP study + ablation 554 (17.7) EP EP study 236 (7.5) Ablation 70 (2.2) EP study + ablation + cardioversion 20 (0.6) EP study + drug challenge 5 (0.2) EP study + cardioversion 4 (0.1) Cardioversion 73 (2.3) Other Drug challenge 29 (0.9) Other procedure 11 (0.4) Cardioversion + other procedure 1 (<0.1) ALL 3,134 (100.0)

Electrophysiology and Pacing Electrophysiology Case totals do not reflect all activity due to incomplete year of data acquisition

Page EP 8 QCOR Annual Report 2017 31.2 Cases by category The majority of cases performed were cardiac device procedures accounting for approximately two-thirds (68%) of documented procedures. The remainder of cases were electrophysiology and ablation procedures (28%) with the remainder categorised as other procedures (4%).

Device EP Other

CH

TTH

MBH

SCUH

TPCH

RBWH

PAH

ALL

0% 25% 50% 75% 100% 0% 25% 50% 75% 100% 0% 25% 50% 75% 100%

Figure 9: Proportion of cases by site and category

Table 3: Proportion of cases by case category

SITE Cardiac Device Procedure EP Other Total n (%) n (%) n (%) n (%) CH 112 (100.0) - - 112 (3.6) TTH 208 (61.2) 81 (23.8) 51 (15.0) 340 (10.8) MBH 60 (98.4) - 1 (1.6) 61 (1.9)

SCUH 103 (50.2) 101 (49.3) 1 (0.5) 205 (6.5) and Pacing Electrophysiology TPCH 781 (67.8) 363 (31.5) 8 (0.7) 1,152 (36.8) RBWH 238 (56.7) 161 (38.3) 21 (5.0) 420 (13.4) PAH 629 (74.5) 183 (21.7) 32 (3.8) 844 (26.9) ALL 2,131 (68.0) 889 (28.4) 114 (3.6) 3,134 (100.0) Case totals do not reflect all activity due to incomplete year of data acquisition

QCOR Annual Report 2017 Page EP 9 32 Patient characteristics

32.1 Age and gender Age is an important risk factor for developing cardiovascular disease. The majority of patients were aged 60 years and above (57%). The median age of the overall electrophysiology and pacing patient cohort was 68 years of age. Males had a higher median age of 69 years of age compared to females with a median age of 66 years. The median age of patients undergoing electrophysiology procedures was 57 years compared to 72 years for the cardiac device procedure category.

Male Female

≥85

80-84

75-79

70-74

65-69

60-64

55-59

50-54

45-49

40-44

<40

Electrophysiology and Pacing Electrophysiology 10% 5% 0% 0% 5% 10%

% of total (n=3,134) Figure 10: Proportion of all cases by age group and gender

The median age of the overall electrophysiology and pacing patient cohort was 68 years of age. Males had a higher median age of 69 years of age compared to females with a median age of 66 years. The median age of patients undergoing electrophysiology procedures was 57 years compared to 72 years for the cardiac device procedure category.

Table 4: Median age by gender and case category

Total cases Female Male ALL (n) (years) (years) (years) Device 2,131 72 72 72 EP 889 50 59 57 Other 114 60 59 60 ALL 3,134 66 69 68 Case totals do not reflect all activity due to incomplete year of data acquisition

Page EP 10 QCOR Annual Report 2017 Overall, 61% of patients were male with all procedure categories demonstrating this trend also. The largest proportion of females was represented in the electrophysiology category (45%).

Female Male

Device

EP

Other

ALL

0% 25% 50% 75% 100% 0% 25% 50% 75% 100%

Figure 11: Proportion of cases by gender and category

Table 5: Proportion of cases by gender and category

Total cases Female Male (n) n (%) n (%) Device 2,131 790 (37.1) 1,341 (62.9) EP 889 400 (45.0) 489 (55.0) Other 114 32 (28.3) 82 (71.7) ALL 3,134 1,222 (39.0) 1,912 (61.0) Case totals do not reflect all activity due to incomplete year of data acquisition Electrophysiology and Pacing Electrophysiology

QCOR Annual Report 2017 Page EP 11 32.2 Body mass index Patients classed as having a body mass index (BMI) category of overweight (31%), obese (33%) or morbidly obese (6%) represented slightly less than three quarters of electrophysiology and pacing patients. Patients classed as underweight represented 2% of all cases.

Normal range* Overweight† Obese‡ Morbidly obese§

Device

EP

Other

ALL

0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50%

* BMI 18.5–24.9 kg/m2

† BMI 25–29.9 kg/m2

‡ BMI 30–39.9 kg/m2

§ BMI ≥40 kg/m2 Figure 12: Proportion of cases by BMI and case category Electrophysiology and Pacing Electrophysiology

Page EP 12 QCOR Annual Report 2017 32.3 Aboriginal and Torres Strait Islander status Overall, the proportion of identified Aboriginal and Torres Strait Islander patients undergoing electrophysiology and pacing procedures was 3.9%. This correlates closely to the estimated proportion of Aboriginal and Torres Strait Islander persons within Queensland (4.0%)3. There was large variation between units, with the North Queensland sites seeing a larger proportion of Aboriginal and Torres Strait Islander patients (Figure 13).

CH

TTH

SCUH

TPCH

RBWH

PAH

ALL

0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10%

Figure 13: Proportion of cases by identified Aboriginal and Torres Strait Islander status and site Electrophysiology and Pacing Electrophysiology

QCOR Annual Report 2017 Page EP 13 33 Risk factors and comorbidities

33.1 Coronary artery disease Close to 40% of device patients have reported previous coronary artery disease with that figure almost halving among the electrophysiology patients.

Device

EP

Other

ALL

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Excludes missing data (17%) Figure 14: Proportion of cases by coronary artery disease history and case category

33.2 Family history of sudden cardiac death During the surveyed period, 14% of patients with a family history of sudden cardiac death underwent other procedures. Overall, 75% of these patients had a drug challenge investigation performed.

Electrophysiology and Pacing Electrophysiology Device

EP

Other

ALL

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Excludes missing data (22%) Figure 15: Proportion of cases by sudden cardiac death history and case category

Page EP 14 QCOR Annual Report 2017 33.3 Smoking history Overall, 29% of patients had a history of tobacco use, including 7% being current smokers and 22% former smokers. 29% reported never having smoked and 19% had an unknown smoking history.

Current Former Never Unknown

Device

EP

Other

ALL

0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50%

Excludes missing data (23%) Figure 16: Proportion of cases by smoking status and case category

33.4 Diabetes The prevalence of diabetes was highest in the cardiac device procedure group, with 22% of patients known to be diabetic. 18% of the overall cohort had some form of diabetes under treatment.

Device

EP

Other

ALL

0% 10% 20% 30% 40% 50% Electrophysiology and Pacing Electrophysiology

Excludes missing data (21%) Figure 17: Proportion of cases by diabetes status and case category

33.5 Hypertension Hypertension, defined as receiving antihypertensive medications at the time of case, was present in over 44% of patients irrespective of case type. Patients in the cardiac device procedure category had a greater incidence of hypertension (51%).

Device

EP

Other

ALL

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Excludes missing data (19%)

Figure 18: Proportion of cases by hypertension status and case category

QCOR Annual Report 2017 Page EP 15 33.6 Dyslipidaemia Overall, 33% of patients were treated with statins for dyslipidaemia at the time of case, ranging from 38% for device procedures to 23% in the electrophysiology category.

Device

EP

Other

ALL

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Excludes missing data (21%) Figure 19: Proportion of cases by dyslipidaemia history status and case category

33.7 Atrial arrhythmia history Overall, 36% of patients had a history of an atrial arrhythmia (atrial fibrillation, flutter or other atrial arrhythmia) at the time of case, ranging from 34% for device procedures to 39% in the electrophysiology category.

Device

EP

Other

ALL

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Electrophysiology and Pacing Electrophysiology

Excludes missing data (20%) Figure 20: Proportion of cases by atrial arrhythmia history status and case category

33.8 Heart failure Overall, 16% of patients had a classification of heart failure at the time of case, ranging from 20% for device procedures to 7% in the electrophysiology category.

Device

EP

Other

ALL

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Excludes missing data (24%) Figure 21: Proportion of cases by heart failure history status and case category

Page EP 16 QCOR Annual Report 2017 33.9 Valvular heart disease 18% of patients had a history of valvular heart disease at the time of case, ranging from 21% for device procedures to 11% in the electrophysiology category.

Device

EP

Other

ALL

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Excludes missing data (23%) Figure 22: Proportion of cases by valvular heart disease history and case category

33.10 Other cardiovascular disease and co-morbidities Overall, 5% of patients had a form of other cardiovascular (CV) disease or co-morbidity at the time of case, ranging from 6% for device procedures to 5% in the electrophysiology category.

Device

EP

Other

ALL

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Electrophysiology and Pacing Electrophysiology Excludes missing data (28%) Figure 23: Proportion of cases by CV disease history/co-morbidity and case category

QCOR Annual Report 2017 Page EP 17 33.11 Renal impairment Across the state, 15% of all patients were identified as having impaired renal function (eGFR≤ 89 mL/min/1.73 m2) at the time of their case. Of these patients, the device procedure group had the highest incidence of renal impairment.

Device

EP

Other

ALL

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Figure 24: Proportion of cases by renal impairment status and case category

33.12 Anticoagulation Patients identified as being anticoagulated using either warfarin or non-vitamin K antagonist oral anticoagulants (NOAC) at the time of case made up 29% of the total cohort. Of these, patients in the other procedure category had the highest use of anticoagulants followed by those in the electrophysiology category.

NOAC Warfarin

Device

EP

Other Electrophysiology and Pacing Electrophysiology

ALL

0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50%

Figure 25: Proportion of cases by anticoagulation status and case category

33.13 LV function Overall, 39% of patients were classed as having an impaired left ventricular ejection fraction (LVEF), including 12% with mild LV dysfunction (LVEF between 40%–50%), 13% with moderate LV dysfunction (LVEF between 30%–39%) and 14% with severe LV dysfunction (LVEF less than 30%).

Severe Moderate Mild Normal

Device

EP

Other

ALL

0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50%

Excludes missing data (34%) Figure 26: Proportion of cases by LV function category and case category

Page EP 18 QCOR Annual Report 2017 34 Care and treatment of patients

34.1 Urgency category Urgency categories are based on the time frame which the procedure is clinically indicated. Categorisation is judged by the individual treating clinician. Across the state, category one cases formed the majority of procedures undertaken. Urgency category ranged widely between sites with category one cases varying from 27% to 65%. Further disparity was noted within category three, with statewide variation noted from as little as 5% of case volume through to 48%.

Table 6: Proportion of all cases by urgency category and site

Total cases Category 1* Category 2† Category 3‡ (n) n (%) n (%) n (%) CH 112 49 (43.8) 50 (44.6) 8 (7.1) TTH 340 133 (39.1) 33 (9.7) 4 (1.2) MBH 61 39 (63.9) 13 (21.3) 2 (3.3) SCUH 211 57 (27.8) 36 (17.6) 90 (43.9) TPCH 1154 749 (65.0) 258 (22.4) 112 (9.7) RBWH 420 145 (34.5) 68 (16.2) 202 (48.1) PAH 844 466 (55.2) 172 (20.4) 138 (16.4) ALL 3,134 1,638 (52.3) 630 (20.1) 556 (17.7) Includes missing data 9.9% Case totals do not reflect all activity due to incomplete year of data acquisition * Procedures that are clinically indicated within 30 days † Procedures that are clinically indicated within 90 days ‡ Procedures that are clinically indicated within 365 days Electrophysiology and Pacing Electrophysiology

Device EP Other

CH

TTH

MBH

SCUH

TPCH

RBWH

PAH

ALL

0% 25% 50% 75% 100% 0% 25% 50% 75% 100% 0% 25% 50% 75% 100%

Legend Category 1 Category 2 Category 3

Figure 27: Proportion of all cases by urgency category, procedure category and site

QCOR Annual Report 2017 Page EP 19 34.2 Admission source The majority of all cases were performed on patients classed as outpatients. CH and TTH were the only sites to perform more inpatient procedures than outpatient. Non-admitted inter-hospital transfers accounted for less than 1.0% of all case volume.

Inpatient Outpatient Non-admitted inter-hospital transfer

CH

TTH

MBH

SCUH

TPCH

RBWH

PAH

ALL

0% 25% 50% 75% 100% 0% 25% 50% 75% 100% 0% 25% 50% 75% 100%

Figure 28: Admission source by site

Table 7: Admission source by site

Total cases Outpatient Inpatient Non-admitted (n)* n (%) n (%) inter-hospital transfer n (%) CH 112 55 (49.1) 57 (50.9) - TTH 340 106 (31.2) 210 (61.8) 1 (0.3)

Electrophysiology and Pacing Electrophysiology MBH 61 34 (55.7) 20 (32.8) 4 (6.6) SCUH 205 133 (64.9) 68 (32.2) - TPCH 1152 626 (54.3) 515 (44.7) 10 (0.9) RBWH 420 278 (66.2) 142 (33.8) - PAH 844 454 (53.8) 384 (45.4) - ALL 3,134 1,686 (53.8) 1,396 (44.5) 15 (0.5) * Includes missing data 1.2%

Case totals do not reflect all activity due to incomplete year of data acquisition

Inpatient Outpatient Non-admitted inter-hospital transfer

Device

EP

Other

ALL

0% 25% 50% 75% 100% 0% 25% 50% 75% 100% 0% 25% 50% 75% 100%

Figure 29: Admission source by case category

Page EP 20 QCOR Annual Report 2017 34.3 Admission source and urgency category Category one procedures accounted for the majority of both inpatient and outpatient cases. There was a marked increase in proportions for inpatient procedures with category one cases accounting for over three- quarters of cases. Outpatient procedures demonstrated almost even distribution across the three categories.

Table 8: Outpatient cases by urgency category

Outpatient site Total cases Category 1 Category 2 Category 3 (n)* n (%) n (%) n (%) CH 55 11 (20.0) 34 (61.8) 8 (14.5) TTH 106 46 (43.4) 24 (22.6) 3 (2.8) MBH 34 17 (50.0) 12 (35.3) 1 (2.9) SCUH 139 1 (0.7) 35 (25.2) 95 (68.3) TPCH 627 291 (46.4) 217 (34.6) 99 (15.8) RBWH 278 22 (7.9) 58 (20.9) 193 (69.4) PAH 454 158 (34.8) 143 (31.4) 109 (24.0) ALL 1,686 546 (32.3) 523 (30.9) 508 (30.0) * Includes 6.9% missing data

Case totals do not reflect all activity due to incomplete year of data acquisition

Table 9: Inpatient cases by urgency category

Inpatient site Total cases Category 1 Category 2 Category 3 (n)* n (%) n (%) n (%) CH 57 38 (66.7) 16 (28.1) - TTH 210 85 (40.5) 9 (4.3) 1 (0.5) MBH 20 17 (85.0) 1 (5.0) - SCUH 68 55 (80.9) 1 (1.5) 1 (1.5) TPCH 515 456 (88.5) 35 (6.8) 11 (2.1) Electrophysiology and Pacing Electrophysiology RBWH 142 123 (86.6) 10 (7.0) 9 (6.3) PAH 384 307 (79.9) 29 (7.6) 29 (7.6) ALL 1,396 1,081 (77.4) 101 (7.2) 51 (3.7) * Includes 11.7% missing data Case totals do not reflect all activity due to incomplete year of data acquisition

QCOR Annual Report 2017 Page EP 21 34.4 Device procedures Case types and procedure combinations varied across the state and relates primarily to services provided by individual sites. Single and dual chamber pacemaker implants/generator changes accounted for the majority of cases across the state. In 2018, 5 sites across the state offered biventricular pacemaker (BiV)/ implantable cardioverter defibrillator (ICD) implants with three sites providing leadless pacemaker implants.

Table 10: Cardiac device case types by site

Site Procedure type Case n (%) CH Pacemaker implant/generator change 75 (67.0) Loop recorder implant/explant 32 (28.6) Device explant 3 (2.7) Lead revision/replacement/pocket revision 2 (1.8) TTH Pacemaker implant/generator change 87 (41.8) ICD implant/generator change/upgrade 78 (37.5) BiV ICD implant/generator change/upgrade 15 (7.2) Loop recorder implant/explant 13 (6.3) Lead revision/replacement/pocket revision 7 (3.4) Device explant 3 (1.4) BiV pacemaker implant/generator change/upgrade 3 (1.4) Leadless pacemaker implant 2 (1.0) MBH Pacemaker implant/generator change 38 (63.3) Loop recorder implant/explant 17 (28.3) Lead revision/replacement/pocket revision 3 (5.0) ICD implant/generator change/upgrade 1 (1.7) Device explant 1 (1.7) SCUH Pacemaker implant/generator change 85 (82.5) ICD implant/generator change/upgrade 11 (10.7) BiV ICD implant/generator change/upgrade 3 (2.9) BiV pacemaker implant/generator change/upgrade BiV 2 (1.9) Device explant 1 (1.0)

Electrophysiology and Pacing Electrophysiology Lead revision/replacement/pocket revision 1 (1.0) TPCH Pacemaker implant/generator change 365 (46.7) ICD implant/generator change/upgrade 161 (20.6) Device explant 68 (8.7) Loop recorder implant/explant 52 (6.7) ICD implant/generator change/upgrade BiV 52 (6.7) BiV pacemaker implant/generator change/upgrade BiV 31 (4.0) Leadless pacemaker implant 28 (3.6) Lead revision/replacement/pocket revision 23 (2.9) Temporary pacing system 1 (0.1) RBWH Pacemaker implant/generator change 85 (35.7) Loop recorder implant/explant 62 (26.1) ICD implant/generator change/upgrade 46 (19.3) BiV ICD implant/generator change/upgrade 20 (8.4) BiV pacemaker implant/generator change/upgrade 11 (4.6) Lead revision/replacement/pocket revision 7 (2.9) Device explant 6 (2.5) Temporary pacing system 1 (0.4) PAH Pacemaker implant/generator change 397 (63.1) ICD implant/generator change/upgrade 115 (18.3) Loop recorder implant/explant 48 (7.6) BiV ICD implant/generator change/upgrade 41 (6.5) Lead revision/replacement/pocket revision 13 (2.1) BiV pacemaker implant/generator change/upgrade 4 (0.6) Device explant 7 (1.1) Leadless pacemaker implant 3 (0.5) Insertion of epicardial lead 1 (0.2) ALL 2,131 Case totals do not reflect all activity due to incomplete year of data acquisition

Page EP 22 QCOR Annual Report 2017 34.5 Electrophysiology studies/ablations Electrophysiology studies including radiofrequency ablation were the most common individual procedure performed across all sites, ranging from 46% at TTH to 64% at RBWH.

Table 11: Electrophysiology study/ablation types by site

Site Procedure type Case n (%) TTH Electrophysiology study and radiofrequency ablation 37 (45.7) Electrophysiology study 20 (24.7) Radiofrequency ablation 13 (16.0) Cryotherapy ablation 9 (11.1) Electrophysiology study and cryotherapy ablation 2 (2.5) SCUH Electrophysiology study and radiofrequency ablation 62 (61.4) Electrophysiology study 23 (22.8) Electrophysiology study and cryotherapy ablation 11 (10.9) Cryotherapy ablation 2 (2.0) Radiofrequency ablation 1 (1.0) Electrophysiology study with radiofrequency and cryotherapy ablation 1 (1.0) Electrophysiology study with drug challenge 1 (1.0) TPCH Electrophysiology study and radiofrequency ablation 191 (52.6) Radiofrequency ablation 73 (20.1) Electrophysiology study 71 (19.6) Electrophysiology study and cryotherapy ablation 12 (3.3) Cryotherapy ablation 7 (1.9) Electrophysiology study with drug challenge 5 (1.4) Electrophysiology study with radiofrequency and cryotherapy ablation 4 (1.1) RBWH Electrophysiology study and radiofrequency ablation 103 (64.0)

Electrophysiology study 40 (24.8) and Pacing Electrophysiology Electrophysiology study and cryotherapy ablation 10 (6.2) Radiofrequency ablation 3 (1.9) Electrophysiology study with radiofrequency and cryotherapy ablation 3 (1.9) Electrophysiology study and drug challenge 2 (1.2) PAH Electrophysiology study and radiofrequency ablation 95 (51.9) Radiofrequency ablation 49 (26.8) Electrophysiology study 36 (19.7) Electrophysiology study and cryotherapy ablation 3 (1.6) ALL 889 Case totals do not reflect all activity due to incomplete year of data acquisition

QCOR Annual Report 2017 Page EP 23 34.5.1 Standard vs complex electrophysiology Complex electrophysiology cases using three-dimensional mapping technology or involving pulmonary vein isolation accounted for 42% of the total electrophysiology cases performed in 2017 across five sites.

Standard Complex

PAH

RBWH

SCUH

TPCH

TTH

ALL

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%

Figure 30: Complexity of electrophysiology procedures by site

Table 12: Proportion of standard and complex electrophysiology procedures by site

Site Case type Total Complex EP Standard EP (n) (n) (n) TTH Radiofrequency ablation 50 16 34 Cryotherapy ablation 11 9 2 Electrophysiology study 20 2 18 SCUH Radiofrequency ablation 63 24 39 Electrophysiology study 23 3 20 Cryotherapy ablation 13 12 1 Electrophysiology study with drug challenge 1 - 1 Electrophysiology and Pacing Electrophysiology Radiofrequency and cryotherapy ablation 1 1 - TPCH Radiofrequency ablation 264 144 120 Electrophysiology study 71 21 50 Cryotherapy ablation 19 18 1 Electrophysiology study with drug challenge 5 1 4 Radiofrequency and cryotherapy ablation 4 4 - RBWH Radiofrequency ablation 106 44 62 Electrophysiology study 40 7 33 Cryotherapy ablation 10 7 3 Electrophysiology study with drug challenge 2 - 2 Radiofrequency and cryotherapy ablation 3 1 2 PAH Radiofrequency ablation 144 52 92 Electrophysiology study 36 4 32 Cryotherapy ablation 3 - 3 ALL 889 370 519 Case totals do not reflect all activity due to incomplete year of data acquisition

Page EP 24 QCOR Annual Report 2017 34.5.2 Three-dimensional mapping system The total proportion of electrophysiology cases utilising three-dimensional mapping systems across sites, and distribution across vendors is shown in Table 13. Two vendors account for 91% of all three-dimensional mapping systems used.

Table 13: Three dimensional mapping system type by site

Total cases CARTO ESI Rhythmia ESI + Rhythmia (n) n (%) n (%) n (%) n (%) TTH 18 8 (44.4) 10 (55.6) - - SCUH 27 - 15 (55.6) 12 (44.4) - TPCH 171 93 (54.4) 60 (35.1) 17 (9.9) 1 (0.6) RBWH 57 5 (8.8) 52 (91.2) - - PAH 56 34 (60.7) 22 (39.3) - - ALL 329 140 (42.6) 159 (48.3) 29 (8.8) 1 (0.3) Case totals do not reflect all activity due to incomplete year of data acquisition

34.5.3 Ablation type Radiofrequency ablation is the principal method across all sites, with 91% of all cases utilising this energy.

Radiofrequency Cryotherapy Radiofrequency + Cryotherapy

TTH

SCUH

TPCH

RBWH

PAH

ALL and Pacing Electrophysiology

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%

Figure 31: Ablation type by site

Table 14: Ablation type by site

Total cases Radiofrequency Cryotherapy Radiofrequency (n) n (%) n (%) + Cryotherapy n (%) TTH 61 50 (82.0) 11 (18.0) - SCUH 77 63 (81.8) 13 (16.9) 1 (1.3) TPCH 287 264 (92.0) 19 (6.6) 4 (1.4) RBWH 119 106 (89.1) 10 (8.4) 3 (2.5) PAH 147 144 (98.0) 3 (2.0) - ALL 691 627 (90.7) 56 (8.1) 8 (1.2) Case totals do not reflect all activity due to incomplete year of data acquisition

QCOR Annual Report 2017 Page EP 25 34.5.4 Ablation chamber The most common site for ablation is within the atria, with ventricular ablation being the second most common.

Table 15: Ablation chamber by site

Atrial Ventricular Bypass Tract Bypass tract Epicardium Atrial and (n) (n) (n) and atrial (n) Ventricular (n) (n) TTH 43 1 7 - - - SCUH 63 3 - - - - TPCH 207 64 13 1 1 1 RBWH 106 6 7 - - - PAH 126 8 6 1 - - ALL 545 82 33 2 1 1 Includes 3.9% missing data Case totals do not reflect all activity due to incomplete year of data acquisition Electrophysiology and Pacing Electrophysiology

Page EP 26 QCOR Annual Report 2017 34.5.5 Ablation location – supraventricular The anatomical location of supra ventricular ablation differs slightly across sites. Cavo-tricuspid isthmus (atrial flutter), pulmonary veins (atrial fibrillation) and slow pathway (atrial tachycardia) ablations accounting for 80% of all cases. The remainder of procedures were for accessory pathway ablation.

Table 16: Supraventricular ablation according to anatomical location

Site Ablation category Count (n) TTH Slow pathway 14 Pulmonary veins 12 Cavo-tricuspid isthmus 9 Tricuspid annulus 6 Mitral annulus 4 Coronary sinus ostium 1 Right septum 1 SCUH Pulmonary veins 21 Slow pathway 17 Cavo-tricuspid isthmus 15 Atrioventricular node 4 Coronary sinus ostium 2 Mitral annulus 2 Crista terminalis mid 1 Tricuspid annulus 1 Other 4 TPCH Pulmonary veins 62 Cavo-tricuspid isthmus 56 Slow pathway 48 Mitral annulus 13 Tricuspid annulus 10 Atrioventricular node 7 Coronary sinus ostium 3 Crista terminalis 2 Posteroseptal 2 Right septum 2 and Pacing Electrophysiology Anteroseptal 1 Crista terminalis mid and Right atrial appendage 1 Coronary sinus ostium and Other and Slow pathway and Mitral annulus 1 Slow pathway and Crista terminalis 1 Slow pathway and Coronary sinus body and Other 1 Slow pathway and Coronary sinus ostium 1 Superior vena cava 1 Other 10 RBWH Slow pathway 43 Pulmonary veins 27 Cavo-tricuspid isthmus 25 Atrioventricular node 5 Tricuspid annulus 5 Mitral annulus 2 Posteroseptal 2 Cavo-tricuspid isthmus and Slow pathway 1 Crista terminalis 1 Coronary sinus ostium 1 Slow pathway and left septum 1 Left septum and right septum 1 Other 1 PAH Slow pathway 45 Cavo-tricuspid isthmus 36 Pulmonary veins 36 Atrioventricular node 6 Mitral annulus 6 Tricuspid annulus 6 Right septum 1 Other 3 QCOR Annual Report 2017 Page EP 27 34.5.6 Ablation location – ventricular The anatomical location of ventricular ablation is variable according to site with right ventricular outflow tract ablation making up a quarter of all ventricular ablation cases.

Table 17: Ventricular ablation according to anatomical location

Site Anatomical location Count (n) TTH Right ventricular outflow tract 1 SCUH Right ventricular outflow tract 1 TPCH Right ventricular outflow tract 10 Left ventricular endocardium 8 Pulmonary artery 5 Aorta-mitral continuity 4 Parahisian 4 Mitral annulus 1 Right/left coronary cusp 4 Tricuspid annulus 3 Papillary muscle 2 Aortico-mitral continuity and Right coronary cusp 1 Left posterior fascicle 1 Left ventricular summit 1 Mitral annulus and Slow pathway 1 Parahisian and Tricuspid annulus 1 Postero-medial papillary muscle and Right/left coronary cusp 1 Other 11 RBWH Right ventricular outflow tract 5 Other 1 PAH Right ventricular outflow tract 3

Electrophysiology and Pacing Electrophysiology Mitral annulus 2 Right/left coronary cusp 1 Other 2

Page EP 28 QCOR Annual Report 2017 34.5.7 Ablation category – supraventricular The most frequently ablated clinical arrhythmia was atrial fibrillation accounting for 28% of all supraventricular ablations across all sites, followed by atrial flutter (24%).

Atrioventricular nodal reentry tachycardia

Atrial fibrillation

Atrial flutter

Atrioventricular reentrant tachycardia

Atrioventricular node

Atrial tachycardia

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Figure 32: Proportion of supraventricular arrhythmia requiring ablation

Table 18: Supraventricular ablation according to arrhythmia

Site Ablation category Count (n) TTH Atrial fibrillation 12 Atrial flutter 10 Atrioventricular reentrant tachycardia 10 Atrioventricular nodal reentry tachycardia 15 SCUH Atrial fibrillation 21 Atrial flutter 16 Atrioventricular reentrant tachycardia 3 Atrioventricular nodal reentry tachycardia 17 Electrophysiology and Pacing Electrophysiology Atrial tachycardia 1 Atrioventricular node 4 TPCH Atrial fibrillation 62 Atrial flutter 51 Atrioventricular reentrant tachycardia 28 Atrioventricular nodal reentry tachycardia 50 Atrial tachycardia 12 Atrioventricular node 7 RBWH Atrial fibrillation 27 Atrial flutter 27 Atrioventricular reentrant tachycardia 7 Atrioventricular nodal reentry tachycardia 45 Atrial tachycardia 2 Atrioventricular node 4 PAH Atrial fibrillation 36 Atrial flutter 29 Atrioventricular reentrant tachycardia 12 Atrioventricular nodal reentry tachycardia 48 Atrioventricular node 6 ALL 562 Includes 3.4% missing data Case totals do not reflect all activity due to incomplete year of data acquisition

QCOR Annual Report 2017 Page EP 29 34.5.8 Ablation category – ventricular Ventricular tachycardia ablation accounted for 54% of all ventricular ablations, with 35% of procedures indicated for ventricular ectopy.

Ventricular tachycardia

Ventricular ectopy

Other

Ventricular fibrillation

Atrial tachycardia

Ventricular tachycardia stimulation

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 33: Proportion of ventricular arrhythmia requiring ablation

Table 19: Ventricular ablation according to arrhythmia

Site Ablation category Count (n) TTH Ventricular ectopy 1 SCUH Ventricular ectopy 1 Ventricular tachycardia 1 TPCH Ventricular tachycardia 37 Ventricular ectopy 24 Other 5 Ventricular fibrillation 2 RBWH Ventricular tachycardia 3 Ventricular ectopy 2 Electrophysiology and Pacing Electrophysiology Atrial tachycardia 1 PAH Ventricular tachycardia 4 Ventricular tachycardia stimulation 1 Ventricular ectopy 1 ALL 83 Includes 11.9% missing data Case totals do not reflect all activity due to incomplete year of data acquisition

Page EP 30 QCOR Annual Report 2017 34.6 Other procedures The most common forms of other procedure were cardioversions (65%). Variations in clinical practice across sites can be observed here, with not all cardioversions performed being carried out in the electrophysiology laboratory environment.

Table 20: Other procedures

Total Cardioversion Drug challenge Other (n) n (%) n (%) n (%) TTH 51 40 (78.4) 11 (21.6) - MBH 1 1 (100.0) - - SCUH 1 - 1 (100.0) - TPCH 8 - 1 (12.5) 7 (87.5) RBWH 21 5 (23.8) 14 (66.7) 2 (9.5) PAH 32 28 (87.5) 2 (6.3) 2 (6.3) ALL 114 74 (64.9) 29 (25.4) 11 (9.6) Case totals do not reflect all activity due to incomplete year of data acquisition Electrophysiology and Pacing Electrophysiology

QCOR Annual Report 2017 Page EP 31 35 Procedural complications

Lead complications were the most frequently encountered complication for device procedures and pericardial effusions were the most commonly observed complication across electrophysiology procedures. The summary of complications below denotes complications observed intraprocedurally as well as post procedure. Notation of complications within the QCOR electrophysiology application is the responsibility of site practitioners. The complication rates for procedures in Tables 21 and 22 are reflected as the proportion of the total number of device and electrophysiology procedures respectively. Rarely, the development of an intraprocedural complication such as coronary sinus dissection necessitated a switch of procedure type from BiV implant/ upgrade to a non-BiV device procedure. These are categorised as the final procedure type. The aggregate for all device procedure complications was 4.6%, while all electrophysiology procedures had a 2.6% complication rate.

Table 21: Cardiac device procedure complications

Procedure type Complication Total n (%) Pacemaker implant/generator change Lead complication 17 (0.8) Pericardial effusion with or without tamponade 6 (0.3) Haematoma 5 (0.2) Cardiac arrest 4 (0.2) Infection 3 (0.1) Pneumothorax 3 (0.1) Venous access complication 3 (0.1) Coronary sinus dissection 2 (0.1) Other 9 (0.4) Loop recorder implant/explant Device erosion 1 (<0.1) Drug reaction 1 (<0.1)

Electrophysiology and Pacing Electrophysiology ICD implant/generator change/ Infection 4 (0.2) upgrade Cardiac arrest 3 (0.1) Lead complication 3 (0.1) Drug reaction 3 (0.1) Haematoma 1 (<0.1) Pericardial effusion with or without tamponade 1 (<0.1) BiV ICD implant/generator change/ Coronary sinus dissection 3 (0.1) upgrade Lead dislodgement 3 (0.1) Haematoma 2 (0.1) Cardiac arrest 1 (<0.1) Infection 1 (<0.1) Other 5 (0.2) BiV pacemaker implant/ generator Coronary sinus dissection 3 (0.1) change/upgrade Cerebrovascular accident 1 (<0.1) Lead complication 1 (<0.1) Device explant Lead complication 2 (0.1) Conduction block 1 (<0.1) Coronary sinus dissection 1 (<0.1) Infection 1 (<0.1) Lead revision/replacement/ pocket Lead complication 2 (0.1) revision Pericardial effusion with or without tamponade 1 (<0.1) ALL 97 (4.6) % as proportion of device procedures Case totals do not reflect all activity due to incomplete year of data acquisition

Page EP 32 QCOR Annual Report 2017 Table 22: Electrophysiology procedure complications

Procedure Type Complexity Complication Total n (%) Ablation – cryotherapy Complex EP Resolved phrenic nerve injury 1 (0.1) Ablation – radiofrequency Complex EP Pericardial effusion with tamponade 3 (0.3) Readmission for return of arrhythmia 1 (0.1) Infection 1 (0.1) Transient ischaemic attack 1 (0.1) Standard EP Conduction block 4 (0.4) Atrial arrhythmia requiring cardioversion 2 (0.2) Pericardial effusion with tamponade 2 (0.2) Vasovagal and chest pain 2 (0.2) Readmission for return of arrhythmia 1 (0.1) Sustained atrial fibrillation 1 (0.1) EP study Complex EP Pericardial effusion with tamponade 1 (0.1) Standard EP Pericardial effusion with tamponade 1 (0.1) Atrial arrhythmia requiring cardioversion 1 (0.1) Venous access complication 1 (4.3) ALL 23 (2.6) % as proportion of electrophysiology procedures Case totals do not reflect all activity due to incomplete year of data acquisition Electrophysiology and Pacing Electrophysiology

QCOR Annual Report 2017 Page EP 33 36 Conclusions 37 Recommendations

This first QCOR electrophysiology and pacing report With ongoing improvement and greater detail of details the mix of patients and clinical workloads electrophysiology and pacing data contained in encountered at seven of the eight public cardiac QCOR, clinicians are now able to access quality electrophysiology services. It demonstrates the first reports and information. Collection and analysis of levels of analysis of robust Queensland Health data. this information will continue to be moulded by the With increasing sophistication and in unprecedented experience and requirements of clinicians as well as detail, future reports will be capable of informing by changes in international guidelines and evidence- processes of benchmarking, service review, audit and based practice. research. The QCOR electrophysiology committee embraces Opportunities for improvement have been identified these changes; the development of clinical indicators in some areas of data collection. One of these is will build continuously on previously defined areas of the documentation of catheter ablation outcomes interest. Through the work of the steering committee at intervals after the procedures, to evaluate the and associated departmental staff, contributions to key metric of endurance of procedural success. and outputs from QCOR will continue to evolve and This refinement could assist predictive and risk to play a pivotal role in guiding everyday practice adjustment modelling for these procedures. and decision support for public patients with heart rhythm disorders. Subsequent QCOR electrophysiology and pacing reports, containing more comprehensive data from all sites, will highlight data regarding booking-to- procedure waiting times, for example as they apply to ablation procedures for atrial fibrillation. This should focus attention on longstanding deficiencies in workforce and laboratory access for cardiac ablation procedures in general. The current report details demographics and outcomes for patients who have undergone procedures, but makes no comment on the increasing and potentially unhealthy waiting

Electrophysiology and Pacing Electrophysiology times for cardiac ablation. International clinical guidelines regarding management of heart rhythm disorders continue to evolve as rapidly as the evidence-based applications of new technologies in the most dynamic sub-specialty in cardiology. Future QCOR electrophysiology and pacing reports will frame data analysis around clinical indicators agreed by the Electrophysiology Working Group of the Statewide Cardiac Clinical Network, so as to assess the quality of care uniformly, meticulously, continuously and authoritatively for the first time on a Queensland Health statewide basis. Reporting on the QCOR platform should reinforce the continuing international standard of care for public patients with heart rhythm disorders.

Page EP 34 QCOR Annual Report 2017 Cardiac Rehabilitation Audit Cardiac Rehabilitation Cardiac

QCOR Annual Report 2017 Page CR 1 Cardiac Rehabilitation Cardiac

Page CR 2 QCOR Annual Report 2017 38 Message from the QCOR Cardiac Rehabilitation Committee Chair

A lot of activity has occurred within the realm of cardiac rehabilitation (CR) over the last few years, and we are excited to publish the first annual report of clinical indicators and service throughput for the latter part of 2017. Evidence suggests that a secondary prevention program such as CR reduces hospital readmission and death within the first year after a coronary event by as much as 56% and 30% respectively, and reduces the risk of repeat myocardial infarction.22 Furthermore, some UK analyses have found that more than half (57%) of all potentially eligible patients leave hospital without a referral to an outpatient CR program. Despite this, 71% of patients state they would go to CR if a health professional discussed it with them before leaving hospital.23

The introduction of a CR Quality Incentive Payment (QIP) in December 2016 directed clinical focus toward ensuring that timely Queensland Health referrals were made to CR and that those patients were assessed within 28 days of being discharged from hospital.

Concurrently, the incoming Queensland Government provided three-year project funding to improve referral to, uptake of, and quality of outpatient CR services. With this financial support, QCOR was able to concentrate on and generate a CR-specific web-based module that supported clinical practice. A new registry tool was built to not only capture clinical indicators and key data points for reporting purposes, but also supported the practice of CR service delivery at the point of care. The QCOR CR module enables the generation of electronic referrals as well as pre- and post CR intervention assessments.

In July 2017, the QCOR CR module was released for use among all Queensland public outpatient CR programs and was mandated as the tool to capture CR QIP activity. The initial utilisation of QCOR data has been focused on generating reports that support the CR QIP initiative. For this process, 53 outpatient CR sites were identified and included (some programs deliver from multiple sites) with the vast majority of these programs using the application as part of routine practice by 31 December 2017.

As a frontline CR clinician who has utilised this module since its inception, I can attest to its wide-reaching benefit to our field. The current usability and multifaceted features (data collection, pre/post outcome comparison and report generation), as well as its future capabilities, positions the QCOR CR module as an industry leader.

This first annual report focuses on the front end of the outpatient CR patient journey. There is sufficient data available to comment on the referral to, and uptake of outpatient CR, as well as identified clinical indicators extracted from the pre- assessment phase. Future reports will incorporate post assessment data and allow Rehabilitation Cardiac analysis of changes and improvements in clinical status made by the CR model of care employed.

Stephen Woodruffe Samara Phillips Chair Project Manager QCOR Cardiac Rehabilitation Committee Statewide Cardiac Rehabilitation Project

QCOR Annual Report 2017 Page CR 3 Cardiac Rehabilitation Cardiac

Page CR 4 QCOR Annual Report 2017 39 Key findings

This first Cardiac Rehabilitation (CR) report includes the first 6 months of data collected through the statewide CR database (QCOR Cardiac Rehabilitation module) implemented on 1 July 2017.

Findings of the report include: • 6,368 referrals were made to participating CR programs in the July–December 2017 period. • Overall there were 44 public outpatient CR programs that participated in CR data reporting. • Male patients aged between 65 years and 69 years comprised the largest cohort based on age category and gender. • Of all referrals, 68% patients were male. • The proportion of Aboriginal and Torres Strait Islander patients was 6.6%, with wide variation across the state. This population group was more vastly represented in north Queensland. • Over three-quarters of patients (81%) were overweight, obese or morbidly obese. • Only 34% of patients meet the physical activity guidelines for their age and are sufficiently active. • The majority of patients presented with ischaemic heart disease (65%) with the remainder having either valvular disease (7%) or other diagnoses (28%). • 59% of all referrals received an outpatient CR assessment within any timeframe. • Patients electing to decline (35%), clinically inappropriate referrals (14%) and referred outside Queensland Health (10%) are the main reasons that patients don’t attend an outpatient CR assessment. • A timely referral (within three days of patient discharge) occurred in 94% of cases. • Of the timely referrals, a timely assessment (within 28 days of discharge) occurred in 85% of cases. Cardiac Rehabilitation Cardiac

QCOR Annual Report 2017 Page CR 5 40 Participating sites

Gympie

Noosa

Kingaroy

Nambour Maroochydore

Caloundra

Caboolture

North Lakes Redcliffe Esk

Chermside

Princess Alexandra Hospital COACH Bayside Toowoomba Gatton Inala Eight Mile Plains Laidley Ipswich Logan-Beaudesert

Boonah Gold Coast

Warwick

Mossman Cairns Mareeba Atherton Innisfail Tully

Ingham

Townsville Ayr

Charters Towers Bowen Mt Isa Proserpine Hughenden Mackay Cardiac Rehabilitation Cardiac Capricorn Coast Rockhampton Longreach Gladstone

Biloela

Hervey Bay Maryborough

Charleville Roma Chinchilla-Miles Dalby Tara

Goondiwindi Stanthorpe

Figure 1: Queensland public CR sites

Page CR 6 QCOR Annual Report 2017 Table 1: Participating CR sites by Hospital and Health Service

HHS Cardiac rehabilitation program Participating Cairns and Hinterland Atherton Y Cairns Y Innisfail Y Mareeba Y Mossman Y Tully Y Central Queensland Biloela Y Capricorn Coast Y Gladstone Y Rockhampton Y Central West Longreach Y Darling Downs Chinchilla-Miles Y Dalby Y Goondiwindi Y Kingaroy Y Stanthorpe – Tara Y Toowoomba Y Warwick Y Gold Coast Gold Coast University Hospital Y Health Contact Centre COACH Y Mackay Bowen – Mackay Y Proserpine Y Metro North Caboolture Y Chermside Y North Lakes Y Redcliffe Y Metro South Bayside Y Eight Mile Plains Y Inala Y Logan-Beaudesert Y Princess Alexandra Hospital Y North West Mt Isa Y South West Charleville Y Roma Y Sunshine Coast Caloundra Y Gympie Y

Maroochydore Y Rehabilitation Cardiac Nambour Y Noosa Y Townsville Ayr – Charters Towers – Hughenden – Ingham Y Townsville Y West Moreton Boonah Y* Esk Y* Gatton Y* Ipswich Y Laidley Y* Wide Bay Hervey Bay Y Maryborough Y * Totals for Boonah, Esk, Gatton and Laidley are reported under Ipswich

QCOR Annual Report 2017 Page CR 7 41 Total referrals

44 CR programs (undertaken at 48 sites) participated in data collection for the latter half of 2017. The programs received a total of 6,368 referrals, the majority of which (78%) originated from the inpatient setting. It is important to note that the total referral count may be understated as not all CR programs had been entering referrals from private practice, general practitioners, and self-referrals due to the initial focus on capturing inpatient referrals from public hospitals.

Table 2: Referral sources by CR outpatient program HHS HHS Inpatient Outpatient External n (%) n (%) n (%) Cairns and Hinterland 289 (81.9) 21 (5.9) 43 (12.2) Central Queensland 521 (62.8) 150 (18.1) 159 (19.2) Central West 12 (75.0) 3 (18.8) 1 (6.3) Darling Downs 190 (76.3) 20 (8.0) 39 (15.7) Gold Coast 639 (80.0) 80 (10.0) 80 (10.0) Health Contact Centre 916 (90.9) 86 (8.5) 6 (0.6) Mackay 101 (80.8) 18 (14.4) 6 (4.8) Metro North 451 (67.6) 51 (7.6) 165 (24.7) Metro South 757 (83.2) 27 (3.0) 126 (13.8) North West 34 (68.0) 11 (22.0) 5 (10.0) South West 19 (95.0) 1 (5.0) - Sunshine Coast 496 (90.8) 28 (5.1) 22 (4.0) Townsville 225 (89.3) 24 (9.5) 3 (1.2) West Moreton 195 (48.6) 69 (17.2) 137 (34.2) Wide Bay 119 (83.8) 22 (15.5) 1 (0.7) STATEWIDE 4,964 (78.0) 611 (9.6) 793 (12.5)

For referrals originating from an inpatient setting, the largest referrer was Metro North Hospital and Health Service (HHS) which accounted for over a quarter (28%) of referrals. The largest CR program was the COACH Program (Health Contact Centre) which received 19% of all inpatient referrals.

Table 3: CR inpatient referrals by source and destination HHS HHS Outgoing inpatient referrals Incoming inpatient referrals n (%) n (%) Cairns and Hinterland 250 (5.0) 289 (5.8) Central Queensland 393 (7.9) 521 (10.5) Cardiac Rehabilitation Cardiac Central West - 12 (0.2) Darling Downs 92 (1.9) 190 (3.8) Gold Coast 640 (12.9) 639 (12.9) Health Contact Centre - 916 (18.5) Mackay 108 (2.2) 101 (2.0) Mater Health Services 51 (1.0) - Metro North 1,363 (27.5) 451 (9.1) Metro South 1,002 (20.2) 757 (15.2) North West 5 (0.1) 34 (0.7) South West - 19 (0.4) Sunshine Coast 467 (9.4) 496 (10.0) Townsville 431 (8.7) 225 (4.5) West Moreton 83 (1.7) 195 (3.9) Wide Bay 79 (1.6) 119 (2.4) STATEWIDE 4,964 (100.0) 4,964 (100.0) Page CR 8 QCOR Annual Report 2017 The flow of inpatient referrals from the originating HHS (acute site) to the CR outpatient program HHS is illustrated in the diagram below. The majority of inpatient referrals remained within the originating HHS, though this varied between sites.

Cairns and Hinterland: 289

Cairns and Hinterland: 250

Central Queensland: 521

Central Queensland: 393

Central West: 12 Darling Downs: 92 Darling Downs: 190

Gold Coast: 640

Gold Coast: 639

Mackay: 108

Mater Health Services: 51

Health Contact Centre: 916

Metro North: 1,363 Mackay: 101

Metro North: 451

Metro South: 757 Metro South: 1,002

North West: 34

South West: 19 North West: 5 Cardiac Rehabilitation Cardiac Sunshine Coast: 467 Sunshine Coast: 496

Townsville: 225 Townsville: 431

West Moreton: 195 West Moreton: 83

Wide Bay: 79 Wide Bay: 119

Figure 2: CR inpatient referrals by source and destination HHS

QCOR Annual Report 2017 Page CR 9 42 Patient characteristics

42.1 Age and gender The age distribution of referrals differed for gender. The highest proportion of referrals for both males and females was in the 65 year to 69 year age group, which included 16% of all referrals. Overall, 68% of patients were male and 32% female.

Male Female

≥85

80-84

75-79

70-74

65-69

60-64

55-59

50-54

45-49

40-44

<40

% of total referrals (n=6,368) Figure 3: Referrals by patient gender and age group

Table 4: Median patient age by gender and HHS

HHS Male Female ALL (years) (years) (years) Cairns and Hinterland 61.3 60.2 61.2 Central Queensland 65.5 67.5 66.3

Cardiac Rehabilitation Cardiac Central West 65.2 66.2 65.2 Darling Downs 65.7 66.4 65.8 Gold Coast 65.8 69.2 67.2 Health Contact Centre 65.3 69.8 66.8 Mackay 63.2 66.9 63.4 Metro North 66.3 68.8 67.1 Metro South 64.1 65.9 64.4 North West 56.2 60.6 59.1 South West 65.5 62.6 64.2 Sunshine Coast 68.9 67.5 68.6 Townsville 63.7 62.5 62.9 West Moreton 64.7 65.7 65.0 Wide Bay 69.3 65.1 69.1 STATEWIDE 65.3 67.3 65.9

Page CR 10 QCOR Annual Report 2017 42.2 Aboriginal and Torres Strait Islander status Aboriginal and Torres Strait Islander patients represented 6.6% of all statewide referrals with considerable variation observed across HHSs. Cairns, North West, South West and Townsville HHSs all reported greater than 15% of case load identifying as Aboriginal and Torres Strait Islander.

Table 5: Aboriginal and Torres Strait Islander status by HHS

HHS Indigenous Non-Indigenous Not stated/unknown n (%) n (%) n (%) Cairns and Hinterland 101 (28.6) 240 (68.0) 12 (3.4) Central Queensland 60 (7.2) 705 (84.9) 65 (7.8) Central West 2 (12.5) 14 (87.5) - Darling Downs 17 (6.8) 229 (92.0) 3 (1.2) Gold Coast 7 (0.9) 748 (93.6) 44 (5.5) Health Contact Centre 87 (8.6) 916 (90.9) 5 (0.5) Mackay 1 (0.8) 122 (97.6) 2 (1.6) Metro North 23 (3.4) 617 (92.5) 27 (4.0) Metro South 25 (2.7) 866 (95.2) 19 (2.1) North West 17 (34.0) 33 (66.0) - South West 4 (20.0) 16 (80.0) - Sunshine Coast 15 (2.7) 525 (96.2) 6 (1.1) Townsville 40 (15.9) 212 (84.1) - West Moreton 16 (4.0) 267 (66.6) 118 (29.4) Wide Bay 7 (4.9) 132 (93.0) 3 (2.1) STATEWIDE 422 (6.6) 5,642 (88.6) 304 (4.8) Cardiac Rehabilitation Cardiac

QCOR Annual Report 2017 Page CR 11 43 Total assessments

CR programs consist of multidisciplinary teams providing health education, physical activity, counselling, behaviour modification strategies and support for patient self-management. The model of care each program implements is dependent upon the local resources and demands. All have a common aim to maximise the physical, psychological and social functioning of people with cardiac disease as well as introduce and encourage behaviours that are known to minimise the risk of further cardiac events and reduce avoidable hospital admissions. The team may comprise of a CR nurse, physiotherapist or exercise physiologist, and other health professionals. CR service delivery may be individual or group-based, and may be located in the home, centre or via virtual means. Regardless of the specific model of care employed by individual CR programs, the main elements of outpatient CR are consistent and include: 1 Assessment, review and follow-up, 2 Low or moderate intensity physical activity, and 3 Education, discussion and counselling. The pre-assessment comprises a review of the presenting, medical and social history as well as a comprehensive cardiac disease risk factor review. The pre-assessment occurs prior to the patient attending a CR program and can be undertaken over the phone or face-to-face. When the identified assessment minimum dataset has been obtained, the assessment is considered complete and for the purposes of QIP, deemed eligible. The number of total referrals proceeded to a pre-assessment (within any timeframe) is 60%.

Table 6: Total pre-assessments completed by HHS

HHS Fully assessed Not assessed Missing data n (%) n (%) n (%) Cairns and Hinterland 232 (65.7) 103 (29.2) 18 (5.1) Central Queensland 409 (49.3) 407 (49.0) 14 (1.7) Central West 13 (81.3) 3 (18.8) - Darling Downs 129 (51.8) 113 (45.4) 7 (2.8) Gold Coast 391 (48.9) 408 (51.1) - Health Contact Centre 578 (57.3) 421 (41.8) 9 (0.9) Mackay 81 (64.8) 44 (35.2) - Metro North 386 (57.9) 281 (42.1) - Metro South 691 (75.9) 219 (24.1) - North West 46 (92.0) 4 (8.0) - South West 14 (70.0) 3 (15.0) 3 (15.0)

Cardiac Rehabilitation Cardiac Sunshine Coast 355 (65.0) 188 (34.4) 3 (0.5) Townsville 116 (46.0) 135 (53.6) 1 (0.4) West Moreton 255 (63.6) 134 (33.4) 12 (3.0) Wide Bay 99 (69.7) 43 (30.3) - STATEWIDE 3,795 (59.6) 2,506 (39.4) 67 (1.1)

Page CR 12 QCOR Annual Report 2017 There are several reasons why patients may not proceed through to a complete assessment. Patients may decline the service, be uncontactable or medically unsuitable for program completion. Interstate referrals also account for a significant proportion of patients not assessed, particularly in the Gold Coast HHS where a high number of patients referred reside in New South Wales. Of those patients referred to CR, 39% do not complete a full assessment which highlights the difficulties encountered in providing services. Patients choosing to decline assessment and intervention represented the most common reason for not proceeding with the CR program. This decline usually occurs when the clinician makes initial contact with the patient. In some instances, the clinician may still opportunistically provide education and advice though this is difficult to document.

Patient declined

Clinically inappropriate

Other reason

Unable to contact

Referred outside of QH

Referred to another program

Failure to attend

Clinically unstable

Readmitted to hospital

Patient deceased

Return to work

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Figure 4: Reasons pre assessment was not conducted

Cardiac Rehabilitation Cardiac

QCOR Annual Report 2017 Page CR 13 44 Clinical presentation

44.1 Diagnosis Patients have been grouped into a diagnosis category for the following analysis. The majority of assessments (65%) were related to a previous diagnosis of ischaemic heart disease (IHD).

Table 7: Assessments by diagnosis and diagnosis category

Diagnosis Category Total n (%) NSTEMI IHD 2,455 (64.7) NSTEMI, Arrhythmia

NSTEMI, Arrhythmia, Other NSTEMI, CHF NSTEMI, CHF, Arrhythmia NSTEMI, CHF, Arrhythmia, Other NSTEMI, CHF, Valvular disease NSTEMI, Other NSTEMI, Stable angina NSTEMI, Unstable angina NSTEMI, Unstable angina, Valvular disease NSTEMI, Valvular disease Stable angina Stable angina, Arrhythmia Stable angina, Other Stable angina, Unstable angina Stable angina, Unstable angina, Other Stable angina, Valvular disease Stable angina, Valvular disease, Other STEMI STEMI, Arrhythmia STEMI, Arrhythmia, Other STEMI, NSTEMI STEMI, Other Unstable angina Unstable angina, Arrhythmia Unstable angina, Arrhythmia, Other Unstable angina, Other Unstable angina, Valvular disease Cardiac Rehabilitation Cardiac Arrhythmia, Valvular disease Valvular disease 278 (7.3) Arrhythmia, Valvular disease, Other

CHF, Valvular disease Valvular disease Valvular disease, Other Arrhythmia Other 1,062 (28.0) Arrhythmia, Other

CHF CHF, Arrhythmia CHF, Other Other Total 3,795 (100.0)

Page CR 14 QCOR Annual Report 2017 44.2 Risk factors and comorbidities The following risk factors and comorbidities are presented according to the diagnosis categories listed in Table 7. These areas are discussed during the assessment phase and self-reported by the patient. It is important to note with self-reporting instances, sometimes the responses are not accurately communicated while the patient and clinician are in the establishment phase of their relationship. As a result, it is expected that some of the risk factor metrics may be understated. There are a number of opportunities for data quality improvement with the steering committee identifying the data definitions as a focus for development. This will ensure that a consistent approach and categorisation can be applied which would allow uniform analyses and comparison between sites.

44.2.1 Smoking At the time of the pre-assessment, 10% of patients were identified as current smokers (defined as smoking within 30 days prior to assessment).

Current smoker Former smoker

IHD

Valvular disease

Other

STATEWIDE

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%

Figure 5: Smoking status by diagnosis category

44.2.2 Body mass index Less than one quarter (18%) of patients were identified as having a BMI within the normal range, while the majority (81%) of patients attending outpatient CR were classified as overweight, obese or morbidly obese. Less than 1% of patients were classified as underweight (BMI <18.5 kg/m2).

Normal weight* Overweight† Obese‡ Morbidly obese§

IHD

Valvular disease

Other Cardiac Rehabilitation Cardiac STATEWIDE

0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50%

* BMI 18.5–24.9 kg/m2

† BMI 25–29.9 kg/m2

‡ BMI 30–39.9 kg/m2

§ BMI ≥40 kg/m2 Figure 6: BMI category by diagnosis category

QCOR Annual Report 2017 Page CR 15 44.2.3 Diabetes Overall, 27% of patients had diabetes as a comorbidity with considerable variation observed between diagnosis categories, ranging from 16% to 31%.

IHD

Valvular disease

Other

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 7: Diabetes by diagnosis category

44.2.4 High blood pressure More than half of patients (62%) were identified as having hypertension, ranging from 53% to 69% across diagnosis categories.

IHD

Valvular disease

Other

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 8: High blood pressure by diagnosis category

44.2.5 Abnormal cholesterol 65% of patients had abnormal cholesterol levels. Abnormal cholesterol levels for patients with known cardiovascular disease include a measure of: • Total cholesterol <4.0mmol/L • HDL >1.0mmol/L • LDL <2.0mmol/L Cardiac Rehabilitation Cardiac • Triglycerides <2.0mmol/L.24

IHD

Valvular disease

Other

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 9: Abnormal cholesterol by diagnosis category

Page CR 16 QCOR Annual Report 2017 44.2.6 Family history of cardiovascular disease 44% of patients had a family history of cardiovascular disease. This had been defined as having a first degree relative diagnosed with cardiovascular disease by the age of 60 years.

IHD

Valvular disease

Other

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 10: Family history of cardiovascular disease by diagnosis category

44.2.7 Heart failure 12% of patients assessed for outpatient CR were documented as having heart failure as a comorbidity.

IHD

Valvular disease

Other

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 11: Heart failure by diagnosis category

44.2.7.1 LV dysfunction Of the patients documented to have heart failure as a comorbidity (Figure 11), 88% were classed as having impaired left ventricular ejection fraction (LVEF). This included 27% with mild LV dysfunction, 37% with moderate LV dysfunction and 23% with severe LV dysfunction. The remainder (12%) were documented as having normal LV function (LVEF >50%).

Mild* Moderate† Severe‡

IHD Rehabilitation Cardiac

Valvular disease

Other

STATEWIDE

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%

* LVEF 40%–49% † LVEF 30%–39% ‡ LVEF <30% Figure 12: Severity of LV dysfunction by diagnosis category

QCOR Annual Report 2017 Page CR 17 44.2.8 History of depression Over one-quarter of patients (27%) had a history of depression prior to experiencing the most recent cardiac event.

IHD

Valvular disease

Other

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 13: History of depression by diagnosis category

44.2.9 Activity level 34% of patients met the physical activity guidelines for their age and were sufficiently active. Conversely, 19% of patients were classed as inactive meaning they only undertake activities associated with daily living.

Sufficiently active Insufficiently active Inactive

IHD

Valvular disease

Other

STATEWIDE

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%

Figure 14: Activity level by diagnosis category

44.2.10 Alcohol consumption The majority of patients indicated at the initial assessment that they did not consume any alcohol at all (60%).25 12% of patients exceeded the guideline of two standard drinks per day.25

No alcohol Within guideline (<=2 / day) Exceeds guideline (>2 / day)

Cardiac Rehabilitation Cardiac IHD

Valvular disease

Other

STATEWIDE

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%

Figure 15: Alcohol consumption by diagnosis category

Page CR 18 QCOR Annual Report 2017 44.3 Current medications

Table 8: Current medications by diagnosis category

Medications IHD Valvular disease Other ALL (%) (%) (%) (%) Aspirin 87.2 57.7 66.9 79.3 ACEI / ARB 61.2 42.3 52.9 57.5 Antiplatelet 64.3 10.0 35.3 52.2 Anticoagulant 15.2 55.9 25.3 21.0 Beta blocker 62.4 48.0 54.0 59.0 Lipid lowering 86.2 53.4 71.0 79.5 Sublingual nitrate 54.6 4.3 28.0 43.5 Diabetic medications 20.4 10.7 21.8 20.1 Diuretic 10.5 29.2 19.2 14.3 Other medications 44.3 57.3 49.6 46.8

Cardiac Rehabilitation Cardiac

QCOR Annual Report 2017 Page CR 19 45 Clinical indicators

For this first annual report, the initial emphasis has been towards the introduction of the QCOR CR module to outpatient programs and the collection of data supporting the CR QIP. The two clinical indicators included are similar to those used by Queensland Health to determine eligibility for the CR QIP reward: 1. Timely referral – proportion of patients receiving a referral to CR within three calendar days of hospital discharge. 2. Timely assessment – proportion of timely referrals to CR where the patient completed an initial CR assessment within 28 days of hospital discharge. For reporting purposes the QCOR CR committee determined that these indicators would be applied to all public inpatient referrals regardless of whether the patient had had an overnight stay (which is required for CR QIP eligibility). Future reports will expand the clinical indicator analysis to include additional clinical performance and quality benchmarks. This will include an analysis of changes in patient risk factors between the CR pre-assessment and post assessment. As data collection continues to evolve, opportunities to examine outcome measures such as patient rehospitalisation and mortality will be explored. Cardiac Rehabilitation Cardiac

Page CR 20 QCOR Annual Report 2017 45.1 Timely referral The vast majority (94%) of referrals generated within a public hospital to a participating CR program were made within three days of the patient being discharged. Performance was consistent across most sites, however, there were some challenges associated with the implementation of the new QCOR module due to logistical and technical barriers. This may explain some observed variation.

Table 9: Inpatient referrals created within three days of discharge from a Queensland Health facility

Referrals (n) Eligible for analysis 4,724 Achieved target 4,440 Target not achieved 284 Ineligible for analysis 1,404 Not a Queensland Health referral 757 Not an inpatient referral 647 Incomplete data 240 Total referrals 6,368

Table 10: Proportion of CR referrals completed within 3 days of hospital discharge by acute site

HHS Acute site Total analysed Met 3 day target (n) (%) Cairns and Hinterland Cairns Hospital 238 94.5 Central Queensland Gladstone Hospital 6 – Rockhampton Hospital 350 97.1 Darling Downs Chinchilla Hospital 1 – Toowoomba Hospital 84 94.0 Gold Coast Gold Coast University Hospital 610 82.8 Mackay Mackay Base Hospital 100 99.0 Proserpine Hospital 1 – Mater Health Services Mater Hospital Brisbane 30 73.3 Metro North Caboolture Hospital 84 96.4 Redcliffe Hospital 13 – Royal Brisbane & Women's Hospital 245 79.6 The Prince Charles Hospital 969 97.5 Metro South Logan Hospital 123 99.2 Rehabilitation Cardiac Princess Alexandra Hospital 800 98.4 Queen Elizabeth II Jubilee Hospital 29 96.6 Redland Hospital 44 97.7 North West Mount Isa Base Hospital 5 – Sunshine Coast Gympie Hospital 6 – Sunshine Coast University Hospital 457 98.5 Townsville The Townsville Hospital 409 93.2 West Moreton Ipswich Hospital 41 85.4 Wide Bay Bundaberg Base Hospital 79 96.2 STATEWIDE 4,724 94.0 Sites not displayed where there are less than 20 cases available for analysis

QCOR Annual Report 2017 Page CR 21 45.2 Timely assessment From the sub-group of patients that receive a timely referral, the timely assessment indicator is calculated. The target is that a comprehensive patient initial assessment occurs within 28 days of the patient being discharged from hospital. There was a total of 4,440 acute referrals which met the target for timely referral, and are thus eligible for this indicator.

Table 11: Acute referrals assessed within 28 days of hospital discharge

Referrals (n) Eligible for analysis 2,624 Achieved target 2,236 Target not achieved 388 Ineligible for analysis 1,771 Patient declined 615 Other reason 375 Clinically unstable / inappropriate 292 Unable to contact 199 Referred outside of Queensland Health 162 Failure to attend 60 Readmitted to hospital 47 Patient deceased 21 Incomplete data 45 Total timely inpatient referrals 4,440

Table 12: Proportion of pre assessments completed within 28 days of hospital discharge by HHS

HHS Total analysed Met 28 day target Median days to (n) (%) assessment Cairns and Hinterland 180 87.2 21 Central Queensland 189 31.2 46 Central West* 9 – – Darling Downs 79 83.5 18 Gold Coast 238 91.2 7 Health Contact Centre 464 85.8 14 Mackay 61 75.4 19 Metro North 254 85.4 15 Metro South 522 92.9 10 Cardiac Rehabilitation Cardiac North West 29 86.2 14 South West* 13 – – Sunshine Coast 319 97.8 13 Townsville 90 94.4 8 West Moreton 103 91.3 13 Wide Bay 74 82.4 20 STATEWIDE 2,624 85.2 14 * Not displayed due to less than 20 assessments available for analysis

Page CR 22 QCOR Annual Report 2017 Table 13: Proportion of pre assessments completed within 28 days of hospital discharge by site

HHS CR program Total analysed Met 28 day Median days to (n) target (%) assessment Cairns and Hinterland Atherton 4 – – Cairns 146 91.8 20 Innisfail 11 – – Mareeba 5 – – Mossman 9 – – Tully 5 – – Central Queensland Biloela 5 – – Capricorn Coast 3 – – Gladstone 42 50.0 28.5 Rockhampton 139 25.9 52 Central West Longreach 9 – 20 Darling Downs Chinchilla-Miles 1 – – Dalby 4 – – Kingaroy 18 – – Toowoomba 46 91.3 16 Warwick 10 – – Gold Coast Gold Coast University Hospital 238 91.2 7 Health Contact Centre COACH 464 85.8 14 Mackay Mackay 52 76.9 19 Proserpine 9 – – Metro North Caboolture 51 92.2 15 Chermside 88 88.6 11 North Lakes 86 75.6 21 Redcliffe 29 93.1 15 Metro South Bayside 122 91.8 11.5 Eight Mile Plains 51 98.0 8 Inala 43 97.7 8 Logan-Beaudesert 213 96.7 7 Princess Alexandra Hospital 93 80.6 21 North West Mt Isa 29 86.2 14 South West Charleville 5 – – Roma 8 – – Sunshine Coast Caloundra 82 100.0 12.5 Gympie 56 98.2 13 Maroochydore 42 100.0 13 Nambour 83 95.2 14 Rehabilitation Cardiac Noosa 56 96.4 14.5 Townsville Ingham 7 – – Townsville 83 100.0 8 West Moreton Ipswich 103 91.3 13 Wide Bay Hervey Bay 51 82.4 20 Maryborough 23 82.6 20 STATEWIDE 2,624 85.2 14 Sites not displayed where there are less than 20 cases available for analysis

QCOR Annual Report 2017 Page CR 23 46 Conclusions 47 Recommendations

This first QCOR report captures 6 months of The introduction of QCOR CR module has provided activity and data relating to 6,368 referrals to 44 a standardised means for capturing structured CR participating outpatient CR programs from July data for the first time. This initial review generates through December 2017. The information provides an unprecedented snapshot of statewide CR practice an initial snapshot of the clinical characteristics of that will be instrumental in development and further patients referred to outpatient CR, while the initial refining of services offered to Queenslanders. To focus has been towards the initial implementation of assist and maintain success of the program, it is the CR module to capture CR QIP activity. recommended that: Going forward, it is hoped that outpatient CR 1. CR clinicians continue the support and programs would use the QCOR CR solution to capture commitment toward the QCOR initiative in all inpatient, outpatient, private, GP and self- order to build a more comprehensive view of referrals, which would allow comprehensive reporting a patient’s journey through CR in Queensland. across the breadth of outpatient CR. This will provide This would include using the CR module for great opportunities for CR programs to undertake all patients attending outpatient CR, such as service planning and reviews using QCOR data. referrals from general practitioners, private hospitals and self-referrals. The report shows that acute sites are performing 2. The registry builds upon existing collaboration well, with 94% of referrals made within three days of with Queensland Health internal partners such hospital discharge even though not all hospitals have as the Clinical Excellence Division and System a dedicated CR nurse seven days per week. This high Performance Reporting to ensure continued level of performance indicates that this responsibility delivery of health service economic benefits can be shared across the hospital community. beyond the initial period of the CR QIP. Timely assessment by the CR outpatient program (pre 3. The QCOR CR module is enhanced to further assessment conducted within 28 days of hospital provide a platform that accommodates the discharge) occurred in 84% of cases. The majority breadth of CR services now and into the of HHSs achieved this target in over 80% of cases, future. These enhancements may consider the however there is considerable variation in target increasing role of mobile devices, telephone- achievement across the state. This should prompt based programs such as COACH and local further exploration and mapping of resourcing, challenges of individual site resourcing and staffing and CR service delivery models. Furthermore, regional accessibility. investigation of the underlying reasons for patients 4. The potential to enhance QCOR beyond declining to attend outpatient CR has been identified the existing dataset is explored, and as a priority for further expansion of the dataset. developed into an extended specification that encompasses further measures in the The Queensland Health CR QIP ceased on 30 June areas of physical wellbeing and exercise. 2018, however key indicators will continue to be Similarly, exploration of alternative quality of monitored through QCOR. The QCOR CR module life measures with the goal of being able to has proven to be very useful in capturing quality provide enhanced patient-centred outcome data to enable benchmarking and allow service indicators. Cardiac Rehabilitation Cardiac improvements to be measured. The transition to 5. The CR module builds upon existing site- the ongoing use of QCOR and implementation of an based initiatives to understand patient needs ongoing clinical indicator program in the absence outside traditional CR offerings. This would of CR QIP is essential to ensure ongoing quality include investigation of declined and non- measurement and benchmarking of care delivery for assessment reasons for service planning as this patient cohort. well as developing the capabilities of QCOR to link with non-Queensland Health services such as interstate health agencies and private CR programs. 6. CR clinicians continue to work collaboratively to expand and develop a comprehensive evidence-based clinical indicator frame-work. This will enable enhanced data quality and improvement in the ability to benchmark statewide clinical practice across participating sites.

Page CR 24 QCOR Annual Report 2017 Heart Failure Support Services Audit Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 1 Heart Failure Support Services Support Heart Failure

Page HF 2 QCOR Annual Report 2017 48 Message from the Heart Failure Services Steering Committee Chairs

It is our pleasure to release the second annual report of clinical performance for Heart Failure Support Services (HFSS) in Queensland Health. The 2017 report presents findings for patients with a diagnosis of heart failure who are referred to one of the 23 multidisciplinary support services across Queensland Health.

Similar to last year, this report presents findings on a range of clinical performance indicators for patients referred to the services in the 2017 calendar year. In addition, this year we are pleased to present 30-day through to 12-month outcome data (mortality, readmission, and time out of hospital) for the 2016 cohort.

The report includes information on a select group of clinical indicators reflective of best practice at a state- wide and local level. Patient outcomes are reported at a statewide level.

We would like to thank the dedicated heart failure nurses and other healthcare providers whose commitment to data collection allows the monitoring of both process and outcome measures of healthcare. This report provides reassurance regarding a number of quality performance measures, and reveals some variations in practice, which will inform healthcare planning and practice at a local level. This report also allows for benchmarking with other jurisdictions and provides valuable information about overall standards of care for patients with chronic heart failure in Queensland.

Finally, we would like to acknowledge the patients and their families referred to heart failure services who have to manage a multitude of factors as a consequence of their chronic condition. We hope that the monitoring of our clinical practice is one small, but important contribution to ensuring that patients receive the best possible clinical care to ultimately live longer and achieve the best quality of life.

A/Prof John Atherton and Ms Tracey Nunan Co-chairs Queensland Heart Failure Services Steering Committee of the SCCN Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 3 49 Key findings

Heart Failure Support Services (HFSS) help patients at high risk of hospitalisation and are comprised of multidisciplinary teams with specialist medical support. Audit findings are summarised below:

Characteristics of referrals to the 21 participating HFSS for 2017 • There were 4,528 new referrals (13% increase from 2016) • Identified Aboriginal andTorres Strait Islander patients made up 4.1% of all referrals • Most referrals to HFSS were: located in South East Queensland (84%); from inpatient settings (71%); male (65%) and with heart failure associated with a reduced left ventricular ejection fraction (HFrEF) (79%) • The overall median age was 70 years with: males younger than females (69 vs 74 years); and those with HFrEF ten years younger than those with a preserved left ventricular ejection fraction (HFpEF) (68 vs 78 years). • A higher proportion of patients with HFpEF were female (55%), whereas patients with HFrEF were predominately male (67%).

Clinical indicators for 2017 Process indicators measured the proportion of eligible patients who received specific interventions. At a statewide level, most indicators met benchmarks except for those relating to beta blocker titration review and achievement.

Table 1: Summary of clinical process indicator performance

# Clinical process indicator measure % referrals 1a First clinical review within 2 weeks for inpatient referrals 79 1b First clinical review within 4 weeks for non-acute referrals 87* 2 Left ventricular ejection fraction (LVEF) assessed within 2 years of referral 94* 3a ACEI/ARB† prescription at hospital discharge 91* 3b ACEI/ARB† prescription at time of first clinical review 92* 4a Beta blocker‡ prescription at hospital discharge 88* 4b Beta blocker‡ prescription at time of first clinical review 89* 5a Beta blocker‡ titration review within six months of first clinical review 71 5b Beta blocker‡ clinical guideline target dose achieved at time of titration review 34 5c Beta blocker‡ clinical guideline target or maximum tolerated dose achieved at time of 70 titration review * Benchmark met (benchmark is 80% achievement except for 5b which is 50%) † Angiotensin-converting-enzyme inhibitor (ACEI) or angiotensin II receptor blockers (ARB) ‡ Bisoprolol, Carvedilol, Metoprolol sustained release, or Nebivolol Heart Failure Support Services Support Heart Failure

Page HF 4 QCOR Annual Report 2017 Patient outcomes Patient outcomes analyses are based on the 2016 cohort to allow for measures to be applied up to 12 months from the index hospitalisation discharge date. Key findings for patients referred from an inpatient setting are summarised in Table 2. Subgroup analysis suggests differences in outcomes according to age and heart failure phenotype.

Table 2: Summary of patient outcomes within one year

# Measures post index hospitalisation* 30 days 1 year 1 All-cause mortality 1.6% 13.6% 2 a) All-cause rehospitalisation 18.3% 57.7% b) Heart failure rehospitalisation 5.8% 22.5% 3 Composite all-cause hospitalisation or all-cause mortality 18.7% 58.7% 4 Days alive and out of hospital† N/A 363 median days‡ * Commences from date of discharge for index admission † A single measure of mortality, readmissions and length of stay ‡ Approximately 60% of patients had additional time in hospital

Recommendations Overall performance with respect to clinical indicators is very high, however the review and titration of beta blockers for up to 6 months remains a challenge for most services. Initial works are currently underway to provide patient management tools to assist HFSS with patient tracking. Departmental resourcing considerations and strategies such as increased nurse-led titration clinics may also assist in ensuring patients receive optimal therapies. Patient outcomes provide important baseline information and will be further enhanced with the collection of clinical data necessary for risk adjustment. While the majority of reported clinical indicators are pharmacological, the dataset should be extended so that non-pharmacological interventions, such as exercise programs, which also impact upon patient outcomes are included for analysis. Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 5 Heart Failure Support Services Audit

50 Participating sites

Queensland HFSS are multidisciplinary teams that assist patients with heart failure (HF) to adhere to treatment and manage symptoms. These teams are comprised of HF nurses with specialist medical support. Some services may include pharmacists, physiotherapists or exercise physiologists, and other allied health professionals.

Statewide coordination of these services provides training and promotes an evidence-based, consistent approach in delivery of care across the state.

Services provided by Queensland HFSS include:

• Active case finding throughout the hospital with an opt-out approach

• Patient and carer education during and post hospitalisation

• Discharge coordination between the inpatient treating team and primary care services, including GP

• Heart failure multidisciplinary clinic and/or telephone-based follow-up or home visits or exercise program

• Medical follow-up that may include heart failure, general cardiology or medical outpatient clinics depending on local resources and patient preferences.

HF nurses entered data relating to all patients referred to their HFSS as part of routine care, using a web- based system which allows reporting of patient characteristics and benchmarking on five clinical indicators. Nurses are provided with weekly reminders regarding fields that require completion and patients due for a review of medication titration status at six months post referral.

When patients are referred onto another HFSS, the audit is completed only for the specific aspect of the journey of care delivered by the site.

Of the 23 HFSS in Queensland, 21 contributed data to this report. The Advanced Heart Failure and Cardiac Transplant Unit (a quaternary unit for Queensland at The Prince Charles Hospital) was not included this year due to interrupted data entry. Toowoomba Hospital was excluded from analysis due to incomplete data, leaving 20 HFSS included in the reporting of clinical indicators. Heart Failure Support Services Support Heart Failure

Page HF 6 QCOR Annual Report 2017 Gympie Hospital

Sunshine Coast University Hospital

Caboolture Hospital Redcliffe Hospital North Lakes Health Precinct

The Prince Charles Hospital Royal Brisbane & Women's Hospital Mater Adult Hospital Princess Alexandra Hospital Redland Hospital Queen Elizabeth II Hospital Toowoomba Hospital Ipswich Community Health Logan Hospital

Gold Coast Community Health

Cairns Hospital

Townsville Hospital

Proserpine Hospital Mt Isa Hospital Mackay Base Hospital

Rockhampton Hospital

Gladstone Hospital

Hervey Bay Hospital Maryborough Hospital

Charleville Community Health Roma Base Hospital

Figure 1: Heart Failure Support Service (HFSS) locations Services Support Heart Failure

QCOR Annual Report 2017 Page HF 7 Table 3 shows the range of activities offered by Queensland HFSS in 2017. All HFSS provide telephone support.

Table 3: Activities offered by Queensland HFSS

HHS* HFSS Inpatient Pharmacist Exercise Group Nurse Home NP† Specialist support therapist rehab clinics visits medical review onsite‡ Cairns and Cairns Hospital Y - YYYYYY Hinterland Central Gladstone Hospital - - Y Y - Y - Telehealth Queensland Rockhampton YY YYYYYY Hospital Darling Toowoomba Hospital Y - Y-YY-Y Downs Gold Coast Gold Coast YY YYYY-Y Community Health Mackay Mackay Base Hospital Y - Y Y Y Y - Y Metro North Caboolture Hospital Y Y --Y--Y Redcliffe Hospital - - ---Y-Y RBWH§ YY Y Y Y - - Y TPCH|| YY YYYYYY Metro South Logan Hospital Y Y YYYYYY Mater Adult Brisbane Y - --YYYY PAH# YY YYYYYY QEII** YY --YYYY Redland Hospital Y - YYYYYY North West Mt Isa Y- - - - Y Y Outreach Sunshine Gympie Hospital Y - - - Y Y Y Outreach Coast SCUH‡‡ Y- --YYYY Townville Townsville Hospital Y Y Y-YYYY West Ipswich Community YY YYYYYY Moreton Health Wide Bay Bundaberg Y- YY---Y Hervey Bay Hospital Y - Y Y Y Y Y Telehealth STATEWIDE 91% 45% 73% 64% 82% 86% 64% 82% * Hospital and Health Service † Nurse practitioner who can prescribe medications ‡ Review by cardiologist or general physician with interest in heart failure § Royal Brisbane & Women’s Hospital || The Prince Charles Hospital # Princess Alexandra Hospital ** Queen Elizabeth II Hospital ‡‡ Includes Nambour General Hospital prior to HFSS relocation to Sunshine Coast University Hospital (SCUH) in March 2017 Heart Failure Support Services Support Heart Failure

Page HF 8 QCOR Annual Report 2017 51 New referrals

In 2017, there were 4,528 new referrals reported by 21 participating HFSS. This represents a 12.6% increase from the first Queensland Cardiac Outcomes Registry (QCOR) HFSS annual report in 2016, where the total number of referrals reported was 4,021. Patients readmitted to hospital whilst being monitored by a HFSS are not counted as a new referral. Most patients are monitored for at least six months to review medication titration.

51.1 Location of referrals The two services reporting the highest number of new referrals were Princess Alexandra Hospital (n=721), followed by The Prince Charles Hospital (n=576).

Table 4: Distribution of new referrals by HFSS location

HHS HFSS n % Cairns and Hinterland Cairns Hospital 128 2.8% Central Queensland Gladstone Hospital 33 0.7% Rockhampton Hospital 197 4.4% Darling Downs Toowoomba Hospital - - Gold Coast Gold Coast Community Health 421 9.3% Mackay Mackay Base Hospital 102 2.3% Metro North Caboolture Hospital 181 4.0% Redcliffe Hospital 92 2.0% Royal Brisbane & Women's Hospital 307 6.8% The Prince Charles Hospital 576 12.7% Metro South Logan Hospital 350 7.7% Mater Adult Hospital 111 2.5% Princess Alexandra Hospital 721 15.9% Queen Elizabeth II Hospital 116 2.6% Redland Hospital 165 3.6% North West Mt Isa Hospital 22 0.5% Sunshine Coast Gympie Hospital 125 2.8% Sunshine Coast University Hospital* 365 8.1% Townsville Townsville Hospital 175 3.9% West Moreton Ipswich Community Health 286 6.3% Wide Bay Bundaberg Hospital - - Hervey Bay Hospital 55 1.2% STATEWIDE 4,528 100.0% * Totals include Nambour General Hospital prior to HFSS relocation to Sunshine Coast University Hospital in March 2017 Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 9 The distribution of referrals between South East Queensland (84%) and the rest of the state (16%) is consistent with the findings of the previous QCOR annual report.

Sunshine Coast 490

Metro North 1,156

West Moreton 286

Metro South Gold 1,463 Coast 421

Cairns and Hinterland 128

North West 22 Townsville 175

Mackay 102

Central Queensland 230

Wide Bay 55

Figure 2: Regional distribution of new referrals Heart Failure Support Services Support Heart Failure

Page HF 10 QCOR Annual Report 2017 51.2 Referral source Most referrals originate from an inpatient setting (71%). Few non-acute referrals came directly from primary care (4%), which may be due to these referrals flowing to specialty outpatient clinics for diagnosis and treatment optimisation prior to referral to a HFSS.

Table 5: Proportion by referral source

HHS HFSS Inpatient Outpatient Another Primary n (%) n (%) HFSS care n (%) n (%) Cairns and Hinterland Cairns Hospital 58 (45.3) 68 (53.1) 2 (1.6) - Central Queensland Gladstone Hospital 13 (39.4) 1 (3.0) 18 (54.5) 1 (3.0) Rockhampton Hospital 104 (52.8) 48 (24.4) 14 (7.1) 31 (15.7) Gold Coast Gold Coast Community Health 291 (69.1) 82 (19.5) 18 (4.3) 30 (7.1) Mackay Mackay Base Hospital 56 (54.9) 42 (41.2) 3 (2.9) 1 (1.0) Metro North Caboolture Hospital 26 (14.4) 53 (29.3) 2 (1.1) 100 (55.2) Redcliffe Hospital 77 (83.7) 13 (14.1) 2 (2.2) - Royal Brisbane & Women's Hospital 249 (81.1) 54 (17.6) 4 (1.3) - The Prince Charles Hospital 533 (92.5) 35 (6.1) 7 (1.2) 1 (0.2) Metro South Logan Hospital 253 (72.3) 29 (8.3) 67 (19.1) 1 (0.3) Mater Adult Hospital 87 (78.4) 23 (20.7) 1 (0.9) - Princess Alexandra Hospital 680 (94.3) 30 (4.2) 11 (1.5) - Queen Elizabeth II Hospital 87 (75.0) 18 (15.5) 10 (8.6) 1 (0.9) Redland Hospital 60 (36.4) 33 (20.0) 69 (41.8) 3 (1.8) North West Mt Isa Hospital 5 (22.7) 16 (72.7) - 1 (4.5) Sunshine Coast Gympie Hospital 68 (54.4) 18 (14.4) 38 (30.4) 1 (0.8) Sunshine Coast University Hospital* 312 (85.5) 44 (12.1) 7 (1.9) 2 (0.5) Townsville Townsville Hospital 110 (62.9) 57 (32.6) 3 (1.7) 5 (2.9) West Moreton Ipswich Community Health 133 (46.5) 106 (37.1) 46 (16.1) 1 (0.3) Wide Bay Hervey Bay Hospital 5 (9.1) 15 (27.3) 31 (56.4) 4 (7.3) STATEWIDE 3,207 (70.8) 785 (17.3) 353 (7.8) 183 (4.0) * Totals include Nambour General Hospital prior to HFSS relocation to Sunshine Coast University Hospital in March 2017 Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 11 52 Patient characteristics

52.1 Age The statewide median age of patients managed by a HFSS was 70 years. The median age of women (74 years) was five years older than for men. The Mt Isa Hospital reported the youngest median age of 56 years and Redcliffe Hospital the oldest median of 79 years. Nearly a quarter of patients were 80 years of age and older.

15%

10%

5%

0% <40 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 ≥ 85

Figure 3: Age groups at referral to a HFSS

Table 6: Median age (years) of referrals by gender

HHS HFSS Male Female ALL Cairns and Hinterland Cairns Hospital 62 63 62 Central Queensland Gladstone Hospital 66 63 64 Rockhampton Hospital 67 71 68 Gold Coast Gold Coast Community Health 71 77 73 Mackay Mackay Base Hospital 72 65 69 Metro North Caboolture Hospital 71 69 70 Redcliffe Hospital 78 79 79 Royal Brisbane & Women's Hospital 67 71 68 The Prince Charles Hospital 72 78 74 Metro South Logan Hospital 68 74 70 Mater Adult Hospital 67 69 68 Princess Alexandra Hospital 66 71 67 Queen Elizabeth II Hospital 73 75 74 Redland Hospital 71 73 71 North West Mt Isa Hospital 57 44 56 Sunshine Coast Gympie Hospital 74 78 76 Sunshine Coast University Hospital* 70 77 72 Townsville Townsville Hospital 63 69 64 West Moreton Ipswich Community Health 67 70 67

Heart Failure Support Services Support Heart Failure Wide Bay Hervey Bay Hospital 72 72 72 STATEWIDE 69 74 70 * Totals include Nambour General Hospital prior to HFSS relocation to Sunshine Coast University Hospital in March 2017 Page HF 12 QCOR Annual Report 2017 52.2 Gender The majority of referrals were males (65%), ranging from 53% to 74% across sites.

Table 7: Number and proportion of referrals to HFSS by gender

HHS HFSS Male Female n (%) n (%) Cairns and Hinterland Cairns Hospital 84 (65.6) 44 (34.4) Central Queensland Gladstone Hospital 21 (63.6) 12 (36.4) Rockhampton Hospital 127 (64.5) 70 (35.5) Gold Coast Gold Coast Community Health 277 (65.8) 144 (34.2) Mackay Mackay Base Hospital 74 (72.5) 28 (27.5) Metro North Caboolture Hospital 118 (65.2) 63 (34.8) Redcliffe Hospital 49 (53.3) 43 (46.7) Royal Brisbane & Women's Hospital 215 (70.0) 92 (30.0) The Prince Charles Hospital 386 (67.0) 190 (33.0) Metro South Logan Hospital 211 (60.3) 139 (39.7) Mater Adult Hospital 63 (56.8) 48 (43.2) Princess Alexandra Hospital 493 (68.4) 228 (31.6) Queen Elizabeth II Hospital 66 (56.9) 50 (43.1) Redland Hospital 99 (60.0) 66 (40.0) North West Mt Isa Hospital 15 (68.2) 7 (31.8) Sunshine Coast Gympie Hospital 73 (58.4) 52 (41.6) Sunshine Coast University Hospital* 240 (65.8) 125 (34.2) Townsville Townsville Hospital 114 (65.1) 61 (34.9) West Moreton Ipswich Community Health 179 (62.6) 107 (37.4) Wide Bay Hervey Bay Hospital 41 (74.5) 14 (25.5) STATEWIDE 2,945 (65.0) 1,583 (35.0) * Totals include Nambour General Hospital prior to HFSS relocation to Sunshine Coast University Hospital in March 2017 Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 13 52.2.1 Gender by age group The age distribution of referrals differed for gender. The highest proportion of referrals for males was in the 70 to 74 years age group (9% of all referrals or 14% of males), and for females the over 85 years category (6% of all referrals or 18% of females).

Male Female

≥ 85

80-84

75-79

70-74

65-69

60-64

55-59

50-54

45-49

40-44

<40

10% 5% 0% 0% 5% 10%

% of total (n=4,528) Figure 4: Proportion of referrals to HFSS by gender and age group Heart Failure Support Services Support Heart Failure

Page HF 14 QCOR Annual Report 2017 52.3 Aboriginal and Torres Strait Islander status Ethnicity is an important determinant of health with a particular impact on the development of cardiovascular disease. In Aboriginal and Torres Strait Islander populations a higher age-adjusted incidence and prevalence of hypertension, coronary artery disease, and rheumatic heart disease has been observed. These are well- recognised pathological precursors for the pathogenesis of symptomatic HF.26 Patients of identified Aboriginal and Torres Strait Islander status made up 4.1% of all HFSS referrals, with considerable variation between services. Cairns, Mount Isa, and Townsville all reported greater than 15% of case load as being Aboriginal and Torres Strait Islander. The highest proportion of Aboriginal and Torres Strait Islander patient referrals was reported by Mt Isa Hospital (46%), while the highest absolute number of referrals for Aboriginal and Torres Strait Islander patients reported by Princess Alexandra Hospital (n=33), followed by Townsville Hospital (n=28).

Table 8: Proportion of identified Aboriginal and Torres Strait Islander patients by HFSS

HHS HFSS n % Cairns and Hinterland Cairns Hospital 23 18.0 Central Queensland Gladstone Hospital 2 6.1 Rockhampton Hospital 13 6.6 Gold Coast Gold Coast Community Health 2 0.5 Mackay Mackay Base Hospital 4 3.9 Metro North Caboolture Hospital 4 2.2 Redcliffe Hospital 0 0.0 Royal Brisbane & Women's Hospital 15 4.9 The Prince Charles Hospital 12 2.1 Metro South Logan Hospital 10 2.9 Mater Adult Hospital 5 4.5 Princess Alexandra Hospital 33 4.6 Queen Elizabeth II Hospital 2 1.7 Redland Hospital 3 1.8 North West Mt Isa Hospital 10 45.5 Sunshine Coast Gympie Hospital 2 1.6 Sunshine Coast University Hospital* 3 0.8 Townsville Townsville Hospital 28 16.0 West Moreton Ipswich Community Health 12 4.2 Wide Bay Hervey Bay Hospital 2 3.6 STATEWIDE 185 4.1 * Totals include Nambour General Hospital prior to HFSS relocation to Sunshine Coast University Hospital in March 2017 Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 15 52.4 Classification of heart failure by left ventricular ejection fraction Heart failure with reduced left ventricular ejection fraction (HFrEF) was defined as patients with an ejection fraction (EF) less than 50% at time of diagnosis. Some patients may return to a normal ejection fraction (greater than 50%) but still require ongoing medications to manage HFrEF.27 The majority (79%) of patients had HFrEF at the time of diagnosis. While information about EF was missing for 5% of patients there was a lot of variation between sites. This suggests that diagnosis is less than optimal at some sites due to poor access to echocardiography.

Table 9: Proportion of patients by heart failure type

HHS HFSS HFrEF* HFpEF† Missing/unsure n (%) n (%) n (%) Cairns and Hinterland Cairns Hospital 123 (96.1) 4 (3.1) 1 (0.8) Central Queensland Gladstone Hospital 29 (87.9) 1 (3.0) 3 (9.1) Rockhampton Hospital 170 (86.3) 26 (13.2) 1 (0.5) Gold Coast Gold Coast Community Health 301 (71.5) 107 (25.4) 13 (3.1) Mackay Mackay Base Hospital 97 (95.1) 5 (4.9) - Metro North Caboolture Hospital 139 (76.8) 32 (17.7) 10 (5.5) Redcliffe Hospital 38 (41.3) 22 (23.9) 32 (34.8) Royal Brisbane & Women's Hospital 255 (83.1) 44 (14.3) 8 (2.6) The Prince Charles Hospital 406 (70.5) 116 (20.1) 54 (9.4) Metro South Logan Hospital 233 (66.6) 92 (26.3) 25 (7.1) Mater Adult Hospital 96 (86.5) 6 (5.4) 9 (8.1) Princess Alexandra Hospital 610 (84.6) 99 (13.7) 12 (1.7) Queen Elizabeth II Hospital 90 (77.6) 20 (17.2) 6 (5.2) Redland Hospital 118 (71.5) 15 (9.1) 32 (19.4) North West Mt Isa Hospital 21 (95.5) 1 (4.5) - Sunshine Coast Gympie Hospital 78 (62.4) 40 (32.0) 7 (5.6) Sunshine Coast University Hospital‡ 311 (85.2) 50 (13.7) 4 (1.1) Townsville Townsville Hospital 162 (92.6) 6 (3.4) 7 (4.0) West Moreton Ipswich Community Health 236 (82.5) 47 (16.4) 3 (1.0) Wide Bay Hervey Bay Hospital 46 (83.6) 9 (16.4) - STATEWIDE 3,559 (78.6) 742 (16.4) 227 (5.0) * Heart failure with reduced ejection fraction † Heart failure with preserved ejection fraction ‡ Totals include Nambour General Hospital prior to HFSS relocation to Sunshine Coast University Hospital in March 2017 Heart Failure Support Services Support Heart Failure

Page HF 16 QCOR Annual Report 2017 The median age for patients with HFrEF was 68 years, compared to a median age of 78 years for patients with HFpEF. The higher proportion of patients with HFpEF were female (55%), whereas patients with HFrEF were predominately male (70%).

Table 10: Type of heart failure by age, gender, and Aboriginal and Torres Strait Islander status

HFrEF* HFpEF† Number 3,559 742 Age (median years) 68 78 Male % 69.8% 45% Indigenous % 4.4% 3.2% Excluding missing data (5.0%) * Heart failure with reduced ejection fraction † Heart failure with preserved ejection fraction

Male Female

≥ 85

80-84

75-79

70-74

65-69

60-64

55-59

50-54

45-49

40-44

<40

10% 5% 0% 0% 5% 10%

% of total with HFrEF (n=3,559) Figure 5: Proportion of HFrEF referrals by gender and age group

Male Female

≥ 85

80-84

75-79

70-74

65-69

60-64

55-59

50-54

45-49

40-44

<40

20% 15% 10% 5% 0% 0% 5% 10% 15% 20%

% of total with HFpEF (n=742) Heart Failure Support Services Support Heart Failure Figure 6: Proportion of HFpEF referrals by gender and age group

QCOR Annual Report 2017 Page HF 17 52.5 Summary of patient characteristics An outline of patient characteristics for all referrals to HFSS is included below.

Table 11: Summary of patient characteristics

Characteristic Summary Participating HFSS 21 New referrals 4,528 Referrals from South East Queensland 84.3% Referral source: Inpatient 70.8% Outpatient 17.3% Another HFSS 7.8% Primary care 4.0% Age (median years): All (median, range by service) 70 (56–79) years Male vs. Female 74 vs 69 years Indigenous vs. non-Indigenous 55 vs 71 years 80 years and over 24.6% Males 65.1% Indigenous 4.1% HFrEF* 78.6% (69.8% male, median age 68 years) HFpEF† 16.4% (45.0% male, median age 78 years) * Heart failure with reduced ejection fraction † Heart failure with preserved ejection fraction Heart Failure Support Services Support Heart Failure

Page HF 18 QCOR Annual Report 2017 53 Clinical indicators

The number of clinical indicators collected was intentionally limited to allow pragmatic data entry as part of routine clinical practice. Consensus on the content and methods of collecting data was reached following a Delphi method involving all HFSS in Queensland. Five process indicators were agreed upon as shown in Table 12. The target benchmark for all indicators was set at 80%, except for 5b (beta blocker titration to clinical guideline target dose at six months) where the benchmark was set at 50%.28

Table 12: Clinical indicators

Indicator # Process measures 1 First Clinical Review: Timeliness of follow-up by a HFSS for inpatient and outpatient referrals 1a) First clinical review within 2 weeks for inpatient referrals 1b) First clinical review within 4 weeks for non-acute referrals 2 Left ventricular ejection fraction (LVEF) assessed within 2 years of referral to HFSS 3 Prescription of angiotensin-converting-enzyme inhibitor (ACEI) or angiotensin II receptor blockers (ARB) for patients with HFrEF 3a) ACEI/ARB prescription at hospital discharge 3b) ACEI/ARB prescription at time of first clinical review 4 Prescription of guideline recommended beta blockers for HFrEF (Bisoprolol, Carvedilol, Metoprolol sustained release, or Nebivolol) 4a) Beta blocker prescription at hospital discharge 4b) Beta blocker prescription at time of first clinical review 5 Beta blocker review and titration 5a) Beta blocker titration review within six months of first clinical review 5b) Beta blocker clinical guideline target dose achieved at time of titration review 5c) Beta blocker clinical guideline target or maximum tolerated dose achieved at time of titration review Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 19 53.1 First clinical review The HFSS review is defined as a clinical (rather than administrative) intervention and can be conducted by phone, clinic, or home visit. Patients were excluded if they died, were referred to another HFSS, declined follow-up or could not be contacted.

1a First clinical review by Heart Failure Support Service within 2 weeks of hospital discharge or date of referral if after discharge (for inpatient referrals). Early post discharge follow-up is recommended for patients with HF to monitor symptoms, provide education and support self-management principles. The appropriate timeframe chosen for this intervention was review within two weeks of hospital discharge or date of referral after recent hospitalisation. Of the 2,097 eligible patients referred from an acute setting, 79% received a clinical review by HFSS within two weeks of hospital discharge. The desired benchmark of 80% was achieved by 9/17 (53%) of HFSS that had more than 20 cases eligible for analysis.

Table 13: Inpatients receiving first HFSS clinical review within 2 weeks of hospital discharge

n % Eligible for analysis 2,097 Achieved benchmark 1,656 79.0% Benchmark not achieved 441 21.0% Ineligible 1,078 Referred to another HFS 603 Other reason 212 Patient declined service 144 Patient could not be contacted 80 Patient deceased 39 Missing data 32 Total acute patients 3,207 Heart Failure Support Services Support Heart Failure

Page HF 20 QCOR Annual Report 2017 HHS HFSS n

Cairns and Hinterland Cairns Hospital 49

Central Queensland Gladstone Hospital 10 N/A

Rockhampton Hospital 101

Gold Coast Gold Coast Community Health 225

Mackay Mackay Base Hospital 51

Metro North Caboolture Hospital 24

Redcliffe Hospital 32

Royal Brisbane & Women's Hospital 150

The Prince Charles Hospital 356

Metro South Logan Hospital 185

Mater Adult Hospital 51

Princess Alexandra Hospital 243

Queen Elizabeth II Hospital 74

Redland Hospital 52

Sunshine Coast Gympie Hospital 59

Sunshine Coast University Hospital* 236

Townsville Townsville Hospital 85

West Moreton Ipswich Community Health 105

Wide Bay Hervey Bay Hospital 5 N/A

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Note: Mt Isa Hospital (North West HHS) is not displayed due to no cases eligible for analysis * Totals include Nambour General Hospital prior to HFSS relocation to Sunshine Coast University Hospital in March 2017 Figure 7: Proportion of inpatients who received first HF Support Service clinical review within 2 weeks of hospital discharge or date of referral if received after discharge Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 21 1b First Heart Failure Support Service clinical review within 4 weeks for non-acute referrals For non-acute patients, the Statewide HF Steering Committee determined four weeks following referral to be the recommended time frame for first clinical review. Referrals for 1,182 eligible patients came from non-acute services, of which 87% received a clinical review within 4 weeks of referral. The desired benchmark of 80% was achieved by 12/16 (75%) of HFSS that had more than 20 cases eligible for analysis.

Table 14: Non-acute patients receiving first HFSS clinical review within 4 weeks of referral

n % Eligible for analysis 1,182 Achieved benchmark 1,026 86.8% Benchmark not achieved 156 13.2% Ineligible 126 Patient declined service 39 Other reason 31 Patient could not be contacted 29 Referred to another HFS 21 Patient deceased 6 Incomplete data 13 Total non-acute patients 1,321 Heart Failure Support Services Support Heart Failure

Page HF 22 QCOR Annual Report 2017 HHS HFSS n

Cairns and Hinterland Cairns Hospital 60

Central Queensland Gladstone Hospital 17 N/A

Rockhampton Hospital 90

Gold Coast Gold Coast Community Health 106

Mackay Mackay Base Hospital 43

Metro North Caboolture Hospital 147

Redcliffe Hospital 9 N/A

Royal Brisbane & Women's Hospital 52

The Prince Charles Hospital 31

Metro South Logan Hospital 81

Mater Adult Hospital 18 N/A

Princess Alexandra Hospital 34

Queen Elizabeth II Hospital 24

Redland Hospital 96

North West Mt Isa Hospital 16 N/A

Sunshine Coast Gympie Hospital 56

Sunshine Coast University Hospital* 50

Townsville Townsville Hospital 60

West Moreton Ipswich Community Health 142

Wide Bay Hervey Bay Hospital 50

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

* Totals include Nambour General Hospital prior to HFSS relocation to Sunshine Coast University Hospital in March 2017 Figure 8: Proportion of non-acute patients who received first HFSS clinical review within 4 weeks of referral Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 23 53.2 Left ventricular ejection fraction (LVEF) assessed within 2 years of referral to HFSS Australian clinical guidelines recommend that all patients with HF should have an assessment of left ventricular function.27 In 94% of cases, LVEF was assessed within two years of referral to HFSS. The benchmark of 80% was achieved by 18 out of 20 (90%) HFSS that had more than 20 cases eligible for analysis.

Table 15: Patients who had LVEF assessed within two years of referral

n % Eligible for analysis 4,513 Achieved benchmark 4,243 94.0% Benchmark not achieved 270 6.0% Ineligible N/A Incomplete data 15 Total referrals 4,528 Heart Failure Support Services Support Heart Failure

Page HF 24 QCOR Annual Report 2017 HHS HFSS n

Cairns and Hinterland Cairns Hospital 128

Central Queensland Gladstone Hospital 33

Rockhampton Hospital 197

Gold Coast Gold Coast Community Health 421

Mackay Mackay Base Hospital 102

Metro North Caboolture Hospital 179

Redcliffe Hospital 92

Royal Brisbane & Women's Hospital 307

The Prince Charles Hospital 564

Metro South Logan Hospital 350

Mater Adult Hospital 110

Princess Alexandra Hospital 721

Queen Elizabeth II Hospital 116

Redland Hospital 165

North West Mt Isa Hospital 22

Sunshine Coast Gympie Hospital 125

Sunshine Coast University Hospital* 365

Townsville Townsville Hospital 175

West Moreton Ipswich Community Health 286

Wide Bay Hervey Bay Hospital 55

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

* Totals include Nambour General Hospital prior to HFSS relocation to Sunshine Coast University Hospital in March 2017 Figure 9: Proportion of all patients who had LVEF assessed within two years of referral to HFSS

Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 25 53.3 Prescription of ACEI or ARB for patients with HFrEF Angiotensin-converting-enzyme inhibitor (ACEI) or angiotensin II receptor blockers (ARB) have been shown to reduce mortality and morbidity in patients with HFrEF and are recommended for all symptomatic patients unless contraindicated or not tolerated.

3a ACEI or ARB prescription for HFrEF at hospital discharge In 2017, 91% of patients referred to a HFSS were prescribed an ACEI or ARB therapy on hospital discharge. The benchmark of 80% was achieved by 16/17 (90%) of HFSS that had more than 20 cases eligible for analysis.

Table 16: Inpatients on ACEI or ARB at time of hospital discharge

n % Eligible for analysis 2,182 Achieved benchmark 1,974 90.5% Benchmark not achieved 208 9.5% Ineligible 907 Documented contraindication* 159 Not HFrEF 613 LV Function assessment not available 135 Incomplete data 118 Total acute patients 3,207 * Adverse reaction to ACEI or ARB, palliative intent to treatment, pregnancy, eGFR <30 mL/min, severe aortic stenosis, renal artery stenosis, serum potassium >5.5 mmol/L, symptomatic hypotension Heart Failure Support Services Support Heart Failure

Page HF 26 QCOR Annual Report 2017 HHS HFSS n

Cairns and Hinterland Cairns Hospital 55

Central Queensland Gladstone Hospital 11 N/A

Rockhampton Hospital 76

Gold Coast Gold Coast Community Health 190

Mackay Mackay Base Hospital 50

Metro North Caboolture Hospital 13 N/A

Redcliffe Hospital 29

Royal Brisbane & Women's Hospital 197

The Prince Charles Hospital 260

Metro South Logan Hospital 143

Mater Adult Hospital 61

Princess Alexandra Hospital 534

Queen Elizabeth II Hospital 55

Redland Hospital 34

North West Mt Isa Hospital 4 N/A

Sunshine Coast Gympie 23

Sunshine Coast University Hospital* 250

Townsville Townsville Hospital 99

West Moreton Ipswich Community Health 96

Wide Bay Hervey Bay Hospital 2 N/A

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

* Totals include Nambour General Hospital prior to HFSS relocation to Sunshine Coast University Hospital in March 2017 Figure 10: Proportion of patients who were on ACEI or ARB therapy at time of hospital discharge Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 27 3b ACEI or ARB prescription for HFrEF at time of first HFSS clinical review At the time of first clinical review, the target for prescription of ACEI or ARB was met for 92% of patients. The benchmark of 80% was achieved by 18/18 (100%) of HFSS that had more than 20 cases eligible for analysis.

Table 17: Patients on an ACEI or ARB at first clinical review

n % Eligible for analysis 2,385 Achieved benchmark 2,191 91.9% Benchmark not achieved 194 8.1% Ineligible 2,053 Referred to another HFSS 624 Not HFrEF 608 Other reason 243 Patient declined service 183 Documented contraindication* 141 Patient could not be contacted 109 LV function assessment not available 100 Patient deceased 45 Incomplete data 90 Total referrals 4,528 * Adverse reaction to ACEI or ARB, palliative intent to treatment, pregnancy, eGFR <30 mL/min, severe aortic stenosis, renal artery stenosis, serum potassium >5.5 mmol/L, symptomatic hypotension Heart Failure Support Services Support Heart Failure

Page HF 28 QCOR Annual Report 2017 HHS HFSS n

Cairns and Hinterland Cairns Hospital 101

Central Queensland Gladstone Hospital 25

Rockhampton Hospital 158

Gold Coast Gold Coast Community Health 225

Mackay Mackay Base Hospital 87

Metro North Caboolture Hospital 111

Redcliffe Hospital 11 N/A

Royal Brisbane & Women's Hospital 155

The Prince Charles Hospital 221

Metro South Logan Hospital 172

Mater Adult Hospital 60

Princess Alexandra Hospital 210

Queen Elizabeth II Hospital 63

Redland Hospital 100

North West Mt Isa Hospital 19 N/A

Sunshine Coast Gympie 66

Sunshine Coast University Hospital* 231

Townsville Townsville Hospital 131

West Moreton Ipswich Community Health 194

Wide Bay Hervey Bay Hospital 45

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

* Totals include Nambour General Hospital prior to HFSS relocation to Sunshine Coast University Hospital in March 2017 Figure 11: Proportion of patients on ACEI or ARB therapy at time of first clinical review by site

Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 29 53.4 Prescription of guideline recommended beta blockers for HFrEF Guideline recommended beta blockers have been shown to reduce mortality and morbidity in patients with HFrEF and are recommended for all symptomatic patients unless contraindicated or not tolerated.27 Guideline recommended beta blockers include: Bisoprolol, Carvedilol, Metoprolol sustained release, or Nebivolol. Results pertain only to these beta blocker medications.

4a Beta blocker prescription for HFrEF at time of hospital discharge In 2017, 88% of referrals were reported to be on a guideline recommended beta blocker at the time of discharge from hospital. The benchmark of 80% was achieved by 13 out of 16 (81%) of HFSS that had more than 20 cases eligible for analysis.

Table 18: Patients on guideline recommended beta blocker at hospital discharge

n % Eligible for analysis 2,281 Achieved benchmark 2,003 87.8% Benchmark not achieved 278 12.2% Ineligible 808 Not HFrEF 613 LV Function assessment not available 135 Documented contraindication* 60 Incomplete data 118 Total acute patients 3,207 * Adverse reaction to beta blocker, palliative intent to treatment, pregnancy, bradycardia (HR <50bpm), symptomatic hypotension, severe COPD, asthma/reversible airways disease Heart Failure Support Services Support Heart Failure

Page HF 30 QCOR Annual Report 2017 HHS HFSS n

Cairns and Hinterland Cairns Hospital 56

Central Queensland Gladstone Hospital 11 N/A

Rockhampton Hospital 78

Gold Coast Gold Coast Community Health 201

Mackay Mackay Base Hospital 51

Metro North Caboolture Hospital 15 N/A

Redcliffe Hospital 28

Royal Brisbane & Women's Hospital 199

The Prince Charles Hospital 278

Metro South Logan Hospital 155

Mater Adult Hospital 63

Princess Alexandra Hospital 554

Queen Elizabeth II Hospital 61

Redland Hospital 37

North West Mt Isa Hospital 4 N/A

Sunshine Coast Gympie 28

Sunshine Coast University Hospital* 256

Townsville Townsville Hospital 102

West Moreton Ipswich Community Health 102

Wide Bay Hervey Bay Hospital 2 N/A

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

* Totals include Nambour General Hospital prior to HFSS relocation to Sunshine Coast University Hospital in March 2017 Figure 12: Proportion of patients on guideline recommended beta blocker at hospital discharge by site

Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 31 4b Beta blocker prescription for HFREF at time of first HFSS clinical review In 2017, 89% of referrals to HFSS were reported to be on a guideline recommended beta blocker at the time of first clinical review. The desired benchmark of 80% was achieved by 17 out of 18 (94%) of HFSS that had more than 20 cases eligible for analysis.

Table 19: Patients on guideline recommended beta blocker at first clinical review

n % Eligible for analysis 2,465 Achieved benchmark 2,193 89.0% Benchmark not achieved 272 11.0% Ineligible 1,971 Referred to another HFSS 624 Not HFrEF 608 Other reason 243 Patient declined service 183 Patient could not be contacted 109 LV function assessment not available 100 Documented contraindication 59 Patient deceased 45 Incomplete data 92 Total referrals 4,528 * Adverse reaction to beta blocker, palliative intent to treatment, pregnancy, bradycardia (HR <50bpm), symptomatic hypotension, severe COPD, asthma/reversible airways disease Heart Failure Support Services Support Heart Failure

Page HF 32 QCOR Annual Report 2017 HHS HFSS n

Cairns and Hinterland Cairns Hospital 105

Central Queensland Gladstone Hospital 26

Rockhampton Hospital 160

Gold Coast Gold Coast Community Health 232

Mackay Mackay Base Hospital 88

Metro North Caboolture Hospital 121

Redcliffe Hospital 11 N/A

Royal Brisbane & Women's Hospital 158

The Prince Charles Hospital 233

Metro South Logan Hospital 174

Mater Adult Hospital 59

Princess Alexandra Hospital 215

Queen Elizabeth II Hospital 77

Redland Hospital 106

North West Mt Isa Hospital 19 N/A

Sunshine Coast Gympie 70

Sunshine Coast University Hospital* 235

Townsville Townsville Hospital 132

West Moreton Ipswich Community Health 198

Wide Bay Hervey Bay Hospital 46

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

* Totals include Nambour General Hospital prior to HFSS relocation to Sunshine Coast University Hospital in March 2017 Figure 13: Proportion of patients on guideline recommended beta blocker therapy at first clinical review by site Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 33 53.5 Beta blocker titration This indicator looks at the progress of titration of guideline recommended beta blockers at six months following hospital discharge or when deactivated from the HFSS, whichever is sooner. The time frame is taken from the first clinical review by HFSS (usually at four weeks from referral or hospital discharge). The indicator measures three components of beta blocker titration at six months, including: a) Review of titration status undertaken, b) Achievement of target dose, and c) Achievement of target or maximum tolerated dose.

5a Beta blocker titration review conducted within six months of first HFSS clinical review Patients who received a beta blocker titration review at six months from referral or at the time of deactivation from the HFSS (whichever is sooner). In 2017, 71% of patients received a beta blocker titration review at six months from referral or at the time of deactivation from the HFSS (whichever was sooner). The benchmark of 80% was achieved by 7/17 (41%) of HFSS that had more than 20 cases eligible for analysis.

Table 20: Patients who had a beta blocker titration review within six months

n % Eligible for analysis 1,588 Achieved benchmark 1,123 70.7% Benchmark not achieved 465 29.3% Ineligible 1,624 Not HFrEF 547 Patient on target dose at the time of referral 395 Other reason 242 LV function assessment not available 93 Patient declined service 91 Referred to another HFSS 84 Documented contraindication* 66 Patient could not be contacted 62 Patient deceased 44 Incomplete data 95 Cases due for beta blocker review 3,313 * Adverse reaction to beta blocker, palliative intent to treatment, pregnancy, bradycardia (HR <50bpm), symptomatic hypotension, severe COPD, asthma/reversible airways disease Heart Failure Support Services Support Heart Failure

Page HF 34 QCOR Annual Report 2017 HHS HFSS n

Cairns and Hinterland Cairns Hospital 92

Central Queensland Gladstone Hospital 21

Rockhampton Hospital 178

Gold Coast Gold Coast Community Health 112

Mackay Mackay Base Hospital 73

Metro North Caboolture Hospital 13 N/A

Royal Brisbane & Women's Hospital 113

The Prince Charles Hospital 130

Metro South Logan Hospital 126

Mater Adult Hospital 38

Princess Alexandra Hospital 114

Queen Elizabeth II Hospital 60

Redland Hospital 34

North West Mt Isa Hospital 8 N/A

Sunshine Coast Gympie 46

Sunshine Coast University Hospital* 146

Townsville Townsville Hospital 112

West Moreton Ipswich Community Health 115

Wide Bay Hervey Bay Hospital 57

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

* Note: Redcliffe Hospital (Metro North HHS) is not displayed due to no cases eligible for analysis † Totals include Nambour General Hospital prior to HFSS relocation to Sunshine Coast University Hospital in March 2017 Figure 14: Proportion of patients who had a beta blocker titration review conducted within six months by site Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 35 5b Beta blocker clinical guideline target dose achieved at time of titration review Daily target doses are: • Carvedilol 50–100 mg • Metoprolol sustained release 190 mg • Bisoprolol 10 mg • Nebivolol 10 mg

Only 34% of referrals achieved target dose for guideline recommended beta blocker medication by the time of titration review at six months. The benchmark of 50% was achieved by 2 out of 17 (12%) of HFSS that had more than 20 cases eligible for analysis.

Table 21: Patients who achieved target beta blocker dose at time of titration review

n % Titration reviews conducted 1,588 Achieved benchmark 545 34.3% Benchmark not achieved 1,043 65.7% Heart Failure Support Services Support Heart Failure

Page HF 36 QCOR Annual Report 2017 HHS HFSS n

Cairns and Hinterland Cairns Hospital 92

Central Queensland Gladstone Hospital 21

Rockhampton Hospital 178

Gold Coast Gold Coast Community Health 112

Mackay Mackay Base Hospital 73

Metro North Caboolture Hospital 13 N/A

Royal Brisbane & Women's Hospital 113

The Prince Charles Hospital 130

Metro South Logan Hospital 126

Mater Adult Hospital 38

Princess Alexandra Hospital 114

Queen Elizabeth II Hospital 60

Redland Hospital 34

North West Mt Isa Hospital 8 N/A

Sunshine Coast Gympie 46

Sunshine Coast University Hospital* 146

Townsville Townsville Hospital 112

West Moreton Ipswich Community Health 115

Wide Bay Hervey Bay Hospital 57

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

* Note: Redcliffe Hospital (Metro North HHS) is not displayed due to no cases eligible for analysis † Totals include Nambour General Hospital prior to HFSS relocation to Sunshine Coast University Hospital in March 2017 Figure 15: Proportion of patients who achieved target beta blocker dose at time of titration review by site Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 37 5c Beta blocker titration clinical guideline target or maximum tolerated dose achieved at time of titration review The number of patients reaching the target dose or maximum tolerated dose of guideline recommended beta blocker medication by the time of titration review at six months was 70%. The benchmark of 80% was achieved by 5/17 (29%) of HFSS that had more than 20 cases eligible for analysis.

Table 22: Patients who achieved target or maximum tolerated beta blocker dose at time of titration review

n % Titration reviews conducted 1,588 Achieved benchmark 1,106 69.6% Benchmark not achieved 482 30.4% Heart Failure Support Services Support Heart Failure

Page HF 38 QCOR Annual Report 2017 HHS HFSS n

Cairns and Hinterland Cairns Hospital 92

Central Queensland Gladstone Hospital 21

Rockhampton Hospital 178

Gold Coast Gold Coast Community Health 112

Mackay Mackay Base Hospital 73

Metro North Caboolture Hospital 13 N/A

Royal Brisbane & Women's Hospital 113

The Prince Charles Hospital 130

Metro South Logan Hospital 126

Mater Adult Hospital 38

Princess Alexandra Hospital 114

Queen Elizabeth II Hospital 60

Redland Hospital 34

North West Mt Isa Hospital 8 N/A

Sunshine Coast Gympie 46

Sunshine Coast University Hospital* 146

Townsville Townsville Hospital 112

West Moreton Ipswich Community Health 115

Wide Bay Hervey Bay Hospital 57

STATEWIDE

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

* Note: Redcliffe Hospital (Metro North HHS) is not displayed due to no cases eligible for analysis † Totals include Nambour General Hospital prior to HFSS relocation to Sunshine Coast University Hospital in March 2017 Figure 16: Proportion of patients who achieved target beta blocker dose or maximum tolerated dose at time of titration review Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 39 53.6 Summary of clinical indicators The performance on clinical indicators is summarised in the Table 23, showing the proportions of all eligible (ideal) patients who received specific interventions. Benchmarks were set at 80% for all indicators except 5b (titration of beta blockers to clinical guideline target dose), which was 50%. Performance was at or above benchmarks for: • CI 1b (follow-up of non-acute patients in four weeks) • CI 2 (LVEF assessment within two years) • CI 3 (ACEI/ARB prescription at hospital discharge and at first clinical eview)r • CI 4a and 4b (beta blocker prescription at hospital discharge and at first clinical review).

Areas in need of improvement were: • CI 1a (follow-up of inpatients in two weeks); and • CI 5a, 5b and 5c (beta blocker titration review and achievement of clinical guideline target dose). Variation between sites allows for targeted quality improvement interventions. Heart Failure Support Services Support Heart Failure

Page HF 40 QCOR Annual Report 2017 Table 23: Summary of clinical process indicator performance by site

Clinical Indicator achievement % HHS HFSS 1a 1b 2 3a 3b 4a 4b 5a 5b 5c Cairns and Hinterland Cairns Hospital 65 90 98 87 95 96 90 96 29 53 Central Queensland Gladstone Hospital – – 94 – 84 – 96 52 43 57 Rockhampton Hospital 46 63 100 91 84 85 73 15 23 47 Gold Coast Gold Coast Community Health 95 95 92 85 88 85 90 77 31 69 Mackay Mackay Base Hospital 73 88 100 96 97 96 91 70 45 78 Metro North Caboolture Hospital 88 81 94 – 93 – 93 – – – Redcliffe Hospital 94 – 64 59 – 82 – – – – Royal Brisbane & Women's Hospital 83 94 96 95 95 93 87 56 33 76 The Prince Charles Hospital HFS 66 77 93 90 91 92 93 71 51 80 Metro South Logan Hospital 71 93 92 87 88 90 90 96 41 84 Mater Adult Hospital 63 – 96 95 88 97 90 97 26 42 Princess Alexandra Hospital 90 68 97 92 95 80 89 89 28 67 Queen Elizabeth II Hospital 69 63 94 86 97 82 88 58 33 75 Redland Hospital 96 98 78 94 95 100 94 71 26 65 North West Mt Isa Hospital – – 100 – – – – – – – Sunshine Coast Gympie Hospital 97 96 90 87 91 71 84 98 28 91 Sunshine Coast University Hospital* 92 88 99 93 94 95 92 84 39 88 Townsville Townsville Hospital 94 95 95 89 91 95 90 100 27 57 West Moreton Ipswich Community Health 70 90 97 90 92 78 86 61 33 59 Wide Bay Hervey Bay Hospital – 100 100 – 98 – 89 42 54 89 STATEWIDE 79 87 94 91 92 88 89 71 34 70 * Totals include Nambour General Hospital prior to HFSS relocation to Sunshine Coast University Hospital in March 2017 Legend: 1a Follow-up of acute patients within 2 weeks 1b Follow-up of non-acute patients within 4 weeks 2 Assessment of left ventricular ejection fraction within 2 years 3a Angiotensin-converting-enzyme inhibitor or angiotensin II receptor blockers prescription at hospital discharge 3b Angiotensin-converting-enzyme inhibitor or angiotensin II receptor blockers prescription at first clinical review 4a Guideline recommended beta blocker prescription at hospital discharge 4b Guideline recommended beta blocker prescription at first clinical review 5a Beta blocker titration status review at six months post referral 5b Beta blockers achievement of guideline recommended target dose (bench mark 50%) 5c Beta blockers achievement of guideline recommended target dose or maximum tolerated dose Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 41 54 Patient outcomes

Heart failure hospitalisations are associated with subsequent increased risk of mortality and recurrent hospitalisation. Multidisciplinary HF disease management programmes such as HFSS and adherence to guideline recommended therapies are associated with improved post-discharge outcomes. As part of this continuing quality improvement initiative, we sought to report the clinical outcomes of inpatient referrals to HFSS during 2016.

54.1 Methods

54.1.1 Data source

This analysis utilised the previously reported 2016 patient cohort29 in the QCOR HFSS registry to examine the early (30-day) and one year clinical outcomes (rehospitalisation and mortality) among patients referred to HFSS through probabilistic data linkage using Queensland Hospital Admitted Patient Data Collection (QHAPDC) and Queensland Registry of Births, Deaths and Marriages.

54.1.2 Analysis eligibility criteria For the purpose of this report, only HFSS referrals initiated during an inpatient encounter for 2016 were included. Where patients had multiple referrals to a HFSS during this period, the earliest admission of the calendar year was considered as the index admission (which may not be the first time that a patient has been hospitalised with heart failure). For the mortality and readmission analysis cohort, eligibility criteria were applied at the time of the index admission, whereas eligibility status for Days alive and out of hospital (DAOH) analysis was reviewed at all subsequent admissions over 12 months, namely to exclude patients who were transferred to private hospitals or interstate.

54.1.3 Clinical outcome measures and statistical analysis The patient outcome measures of interest are summarised in Table 24. All-cause mortality survival curves were constructed using the Kaplan–Meier method. Cumulative incidence function was used to estimate the risk of all-cause and HF related re-hospitalisation to account for the competing risk of death. DAOH was calculated to reflect the burden of recurrent hospitalisation, hospital length of stay and death, and was expressed as both median values with 25th and 75th percentiles and mean values. Differences in DAOH between sub-groups were compared using Mann-Whitney test. Categorical variables were summarised as frequencies and percentages.

Table 24: Patient outcome indicators

Indicator # Measure 1 All-cause mortality within one year after index hospitalisation discharge 2 Rehospitalisation within one year after index hospitalisation discharge a) All-cause rehospitalisation b) Heart failure rehospitalisation 3 Composite of all-cause hospitalisation or all-cause mortality within one year after index hospitalisation discharge 4 Days alive and out of hospital within one year of index hospital discharge date Heart Failure Support Services Support Heart Failure

Page HF 42 QCOR Annual Report 2017 54.2 Findings In 2016, there were 2,868 inpatient referrals reported of which 2,608 referrals were eligible for data linkage. The success rate for linking referrals to administrative and death registry data was 95.5% (n=2,491). A further 51 (1.8%) patients did not have complete follow up of 365 days to allow calculation of DAOH (Table 25).

Table 25: Eligibility criteria for patient outcome indicators

n % Total 2016 inpatient referrals 2,868 100.0 Ineligible at index admission: Duplicate patient record 124 4.3 Not a Queensland resident 65 2.3 Transferred to private hospital 25 0.9 Index admission is not overnight 24 0.8 Died during index admission 22 0.8 No linkage data available 117 4.1 Included in readmission and mortality analysis 2,491 86.9 Ineligible at subsequent admissions for 1 year: Transferred to private hospital 49 1.7 Moved outside of Queensland 2 0.1 Included in days alive and out of hospital analysis 2,440 85.1

54.2.1 All-cause mortality Among patients referred to HFSS during an inpatient encounter, the 30-day and one year unadjusted all- cause mortality rate were 1.6% and 13.6% respectively (Table 26). Survival curves suggest that gender was not associated with all-cause mortality at one year (Figure 17). In contrast, older age was associated with increased all-cause mortality at one year (Figure 18). As an exploratory analysis, we examined the univariate association between the documented HF phenotype and subsequent all-cause mortality (Figure 3). Among this cohort of patients (i.e. those referred to HFSS), patients with documented HFpEF phenotype was associated with increased mortality. However, patients with either unknown or missing HF phenotype documentation were associated with the worst un-adjusted mortality risk (Figure 19).

Table 26: Cumulative all cause unadjusted mortality rate from 30 to 365 days after index discharge date

30 days 90 days 180 days 365 days n (%) n (%) n (%) n (%) Total deaths identified 41 (1.6) 125 (5.0) 201 (8.0) 340 (13.6) Died during subsequent admission* 28 (1.1) 75 (3.0) 123 (4.9) 208 (8.4) All other deaths 13 (0.5) 50 (2.0) 77 (3.1) 132 (5.3) Total at risk 2,450 (98.4) 2,365 (95.0) 2,288 (92.0) 2,149 (86.4) * Data available for Queensland public hospitals only Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 43 Table 27: Cumulative all cause unadjusted mortality by patient characteristic

Total patients 30 days 90 days 180 days 365 days (n) n (%) n (%) n (%) n (%) Gender Male 1,621 27 (1.7) 88 (5.4) 137 (8.4) 231 (14.3) Female 870 14 (1.6) 37 (4.3) 64 (7.4) 109 (12.5) Age group <65 years 852 8 (0.9) 21 (2.5) 29 (3.4) 50 (5.9) 65–74 years 662 12 (1.8) 33 (5.0) 49 (7.4) 78 (11.8) ≥75 years 977 21 (2.1) 71 (7.3) 123 (12.6) 212 (21.7) Heart failure phenotype HFrEF 1,898 30 (1.6) 85 (4.5) 128 (6.7) 225 (11.9) HFpEF 486 7 (1.4) 29 (6.0) 53 (10.9) 89 (18.3) Missing/unsure 107 4 (3.7) 11 (10.3) 20 (18.7) 26 (24.3)

100% 100%

80% 80%

60% 60%

40% 40%

20% 20%

0% 0% 0 90 180 270 360 0 90 180 270 360 Days Days

Figure 17: Heart failure survival by gender Figure 18: Heart failure survival by age group

100%

80%

60%

40%

20%

0%

0 90 180 270 360 Days Heart Failure Support Services Support Heart Failure

Figure 19: Heart failure survival by phenotype

Page HF 44 QCOR Annual Report 2017 54.2.2 All-cause and heart failure rehospitalisation Cumulative incidence curves for all-cause and HF hospitalisation are shown in Figure 20 and 21. Of the 2,491 eligible patients referred to HFSS during 2016, the unadjusted rate of all-cause hospitalisation was 18.3% at 30-day, increasing to 57.7% at one year. HF related hospitalisation rates, as defined by primary discharge diagnosis coding (Appendix A), were 5.8% and 22.5% at 30-day and one year respectively. Collectively, the risk of hospitalisation or death within 12 months after initial discharge among patients referred to HFSS during a hospitalisation was 58.7% at one year (Figure 22). Over 30% of patients referred to HFSS experienced two or more rehospitalisation during the subsequent year (Table 28).

Table 28: Number of rehospitalisations per patient over one year since discharge

All cause rehospitalisation Heart failure rehospitalisation n (%) n (%) None 1,091 (43.8) 1,975 (79.3) 1 rehospitalisation 642 (25.8) 318 (12.8) 2 rehospitalisations 318 (12.8) 123 (4.9) 3 rehospitalisations 182 (7.3) 42 (1.7) 4 rehospitalisations 106 (4.3) 16 (0.6) ≥5 rehospitalisations 152 (6.1) 17 (0.7)

100% 100%

80% 80%

57.7% 60% 60%

43.6%

40% 40% 32.1%

22.5% 18.3% 20% 20% 15.7% 11.5% 5.8%

0% 0% 0 90 180 270 360 0 90 180 270 360 Days Days

Figure 20: Cumulative incidence of all cause Figure 21: Cumulative incidence of heart failure rehospitalisation rehospitalisation

100%

80%

58.7% 60%

44.7%

40% 33.1%

18.7% 20%

0%

0 90 180 270 360 Services Support Heart Failure Days

Figure 22: Cumulative incidence of all-cause rehospitalisation or death QCOR Annual Report 2017 Page HF 45 54.2.2 Days alive and out of hospital Days alive and out of hospital (DAOH) incorporates mortality and all hospitalisations (including length of hospital stay) within one year of discharge into a single measure that reflects the patient’s experience of living with this chronic condition. Although the median DAOH was 363.3 days, only approximately 40% of patients managed to spend no additional time in hospital after initial discharge. Given that days lost due to early mortality or rehospitalisation with prolonged length of stay were driven by a small proportion of patients, we also present mean values to better capture overall burden for the patient cohort (with over 90,000 days lost due to death or hospitalisation in the total cohort of 2,440 patients over 12 months).

50%

40%

30%

20%

10%

0% <90 90-179 180-269 270-364 365

Days

Figure 23: Days alive and out of hospital within one year after hospital discharge

Similar to mortality risk, we observed a lower DAOH among HFSS referrals with HFpEF phenotype compared to HFrEF (median 359.2 vs 364, p<0.001). Elderly patients (aged >75 years) referred to HFSS were also associated with significantly lower DAOH compared to younger (aged <65 years) patients (median 359.7 vs 365, p<0.001) (Figure 24).

Characteristic Group n Mean Median (IQR)

Sex Male 1,590 330 363 (350-365) p 0.1667 Female 850 326.9 363 (346-365)

Age group <65 843 345.8 365 (359-365) p <0.001 65-74 652 330 364 (352-365) p <0.001 p <0.001 ≥75 945 310.8 360 (326-365)

HF phenotype HFrEF 1,873 332.5 364 (352-365) p <0.001

HFpEF 465 317 359 (332-365) p <0.001 p 0.5828 Missing/unsure 102 295.4 360 (297-365)

STATEWIDE - 2,440 328 363 (348-365)

0 30 60 90 120 150 180 210 240 270 300 330 360 Days

Mean, median and interquartile range (IQR) are given in days Figure 24: Days alive and out of hospital within one year of discharge by patient characteristics Heart Failure Support Services Support Heart Failure

Page HF 46 QCOR Annual Report 2017 54.3 Discussion Due to the limited variables collected, multivariate adjustment of clinical outcomes risks was not available for this analysis. This limits our ability to discern independent associations, hence unmeasured confounders may influence the associations observed in this analysis. For the same reason, comparisons of clinical outcomes across individual sites were intentionally avoided in this analysis. This first report of clinical outcomes for patients referred to HFSS highlight the significant burden of morbidity and mortality among patients with HF after hospitalisation, and the impact this has on health care resources. With expanded future analyses, it is expected that improved insight and understanding can be gained. Findings of this analysis also identify that the unadjusted outcomes for the HFpEF phenotype are significantly poorer compared to the HFrEF phenotype. Further investigation into the factors associated with increased risk for the HFpEF cohort is needed. Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 47 55 Conclusions

This second annual QCOR HFSS report captures information on patient referrals to 21 Queensland Heart Failure Support Services. While the statewide figures provide an overview of clinical performance, data from individual services should be treated with caution as underreporting or small patient numbers may not accurately reflect performance. Pleasingly, performance on most clinical process indicators is at or above benchmarks except for review and titration of beta blockers. Measuring the review and titration of beta blocker therapy up to 6 months from referral provides unique information about chronic disease management. This supports the notion that continuity of treatment between acute and primary care sectors is rarely routinely measured and is a significant challenge encountered on a daily basis. While performance on most clinical indicators is high, the variance between sites is considerable and this benchmarking provides valuable information needed for quality improvement initiatives. This vital information is integral to addressing local challenges and barriers to providing contiguous care. Patient outcomes of mortality, readmission, and days alive and out of hospital are measured for the previous cohort for up to 12 months. This provides valuable information about the true impact of heart failure and extends the analytic capacity of this report. Future work that utilises this platform for analysis promises to deliver greater awareness and understanding of the true overarching burden of disease. Heart Failure Support Services Support Heart Failure

Page HF 48 QCOR Annual Report 2017 56 Recommendations

The first report in 2016 made many recommendations that have been implemented or are in development as follows: • Patient outcomes of mortality, readmissions, days alive and out of hospital rates are now reported

• The benchmarking information for clinical process indicators has been reviewed at each site and has resulted in changes in work practices to improve efficiencies as well as submissions for increased staffing (for example: closer review and monitoring of potentially missed referrals may explain the 13% increase in referrals)

Plans are currently underway to: • Provide incentives for data completion by introducing elements that assist with patient management such as production of referrals, assessment and management information to aid in communication

• Introduce new indicators to reflect changes in prescribing, e.g. mineralocorticoid receptor antagonists (MRAs) and monitor the pattern of Angiotensin Receptor Neprilysin Inhibitor (ARNI) prescription

• Collect covariates to allow risk-adjustment of outcomes measures (e.g. eGFR, serum sodium, serum potassium, haemoglobin, iron studies, and comorbidities)

New recommendations: • Support HFSS to improve beta blocker titration by: promoting nurse and pharmacist facilitation of titration (when managed by GP); advocating for more pharmacy and nurse practitioner involvement in care; and providing systems to track patients under titration and for generating titration plans

• Introduce targeted non-pharmacological interventions known to improve quality of life and relieve symptoms; for example, exercise therapy and psycho-social support

• Measure outcomes for all patients regardless of referral source (i.e. for outpatient as well as inpatient referrals) Heart Failure Support Services Support Heart Failure

QCOR Annual Report 2017 Page HF 49 57 Appendix: List of ICD10-AM Codes

ICD10-AM Description Code E87.7 Fluid overload I13.0 Hypertensive heart and kidney disease with (congestive) heart failure I13.2 Hypertensive heart and kidney disease with both (congestive) heart failure and kidney failure I25.5 Ischaemic cardiomyopathy I42.0 Dilated cardiomyopathy I42.1 Obstructive hypertrophic cardiomyopathy I42.2 Other hypertrophic cardiomyopathy I42.5 Other restrictive cardiomyopathy I42.6 Alcoholic cardiomyopathy I42.7 Cardiomyopathy due to drugs and other external agents I42.8 Other cardiomyopathies I42.9 Cardiomyopathy, unspecified I46.0 Cardiac arrest with successful resuscitation I46.1 Sudden cardiac death so described I46.9 Cardiac arrest unspecified I50 Heart failure (includes: congestive heart failure; left ventricular failure; and, heart failure, unspecified) J81 Pulmonary oedema J90 Pleural effusion, not elsewhere classified R18 Ascites R57.0 Cardiogenic shock R60.1 Generalised oedema Heart Failure Support Services Support Heart Failure

Page HF 50 QCOR Annual Report 2017 Interventional Cardiology Audit 58 References 4. National Cardiovascular Data Registry. CathPCI Data Coder’s Dictionary. (2011, January 5). 1. Australian Bureau of Statistics (2016). Regional Retrieved September 27, 2018, from https:// Population Growth, Australia. Cat No. 3218.0. www.ncdr.com/webncdr/cathpci/home/ Canberra: Australian Bureau of Statistics. datacollection 2. Queensland Health (2016). The health of 5. Chew, D. P., Scott, I. A., Cullen, L., French, J. Queenslanders 2016. Report of the Chief Health K., Briffa, T. G., Tideman, P. A., . . . Aylward, Officer Queensland. Brisbane: Queensland P. E. (2017). Corrigendum to ‘National Heart Government. Foundation of Australia & Cardiac Society of 3. Australian Bureau of Statistics (2016). Census of Australia and New Zealand: Australian Clinical Population and Housing – Counts of Aboriginal Guidelines for the Management of Acute and Torres Strait Islander Australians, 2016. Coronary Syndromes 2016’ Heart Lung and Cat No. 2075. Canberra: Australian Bureau of Circulation volume 25, (2016) 898 - 952. Heart, Statistics. Lung and Circulation, 26(10), 1117. 6. Mcallister, K. S., Ludman, P. F., Hulme, W., Belder, M. A., Stables, R., Chowdhary, S., . . . Buchan, I. E. (2016). A contemporary risk model for predicting 30-day mortality following percutaneous coronary intervention in England and Wales. International Journal of Cardiology, 210, 125-132. 7. Andrianopoulos, N., Chan, W., Reid, C., Brennan, A. L., Yan, B., Yip, T, . . . Duffy, S. J. (2014). PW245 Australia’s First PCI Registry-Derived Logistic and Additive Risk Score Calculations Predicting Post-Procedural Adverse Outcomes. Global Heart, 9(1). 8. Hannan, E.L., Farrell, L.S., Walford, G., Jacobs, A.K., Berger, P.B., Holmes, D.R., Stamato, N.J., Sharma, S., King, S.B. (2013). The New York State risk score for predicting in-hospital/30- day mortality following percutaneous coronary intervention. JACC: Cardiovascular Interventions. 30;6(6):614-22. 9. O’Gara, P., Kushner, F., Ascheim, D., Casey, JR D., Chung, M., de Lemos, J., . . . Zhao, D., (2013). 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction A Report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines. Catheterization and Cardiovascular Interventions, 82(1). 10. Ibanez, B., James, S., Agewall, S., Antunes, M.J., Bucciarelli-Ducci, C., Bueno, H., . . . Widimský, P. (2018). 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). European Heart Journal. 39:119-177.

QCOR Annual Report 2017 Page i Cardiac Surgery Audit Cardiac Surgery Audit Supplement 11. Australian Institute of Health and Welfare (2015). 20. Tornos, P. (2005). Infective endocarditis in The health and welfare of Australia’s Aboriginal Europe: Lessons from the Euro heart survey. and Torres Strait Islander peoples. Cat. No. IHW Heart, 91(5), 571-575. 147. Canberra: Australian Institute of Health and Welfare. Electrophysiology and Pacing Audit 12. Roques, F. (2003). The logistic EuroSCORE. 21. Queensland Health: Statewide Cardiac Clinical European Heart Journal, 24(9), 882. Network – Cardiac Electrophysiology and Pacing 13. Billah, B., Reid, C. M., Shardey, G. C., & Smith, Working Group (2010). Queensland Cardiac J.A. (2010). A preoperative risk prediction model Electrophysiology and Pacing – 2010 Report. for 30-day mortality following cardiac surgery in Brisbane: Queensland Government. an Australian cohort. European Journal of Cardio- Thoracic Surgery, 37(5), 1086-1092. Cardiac Rehabilitation Audit 14. Reid, C., Billah, B., Dinh, D., Smith, J., 22. National Health Service of the United Kingdom Skillington, P., Yii, M., . . . Shardey, G. (2009). (2013). NHS Improvement; Heart. Making An Australian risk prediction model for 30-day the case for cardiac rehabilitation: modelling mortality after isolated coronary artery bypass: potential impact on readmissions. London: The AusSCORE. The Journal of Thoracic and National Health Service. Cardiovascular Surgery, 138(4). 23. National Heart Foundation of Australia (2016). 15. Shahian, D. M., Obrien, S. M., Filardo, G., An advocacy toolkit for health professionals: to Ferraris, V. A., Haan, C. K., Rich, J. B., . . improve Cardiac Rehabilitation and Heart Failure .Anderson, R. P. (2009). The Society of Thoracic Services. Sydney: National Heart Foundation of Surgeons 2008 Cardiac Surgery Risk Models: Australia. Part 1—Coronary Artery Bypass Grafting Surgery. The Annals of Thoracic Surgery, 88(1). 24. Vascular Disease Prevention Alliance (2012). Guidelines for the management of absolute 16. Obrien, S. M., Shahian, D. M., Filardo, G., cardiovascular disease risk. Melbourne: National Ferraris, V. A., Haan, C. K., Rich, J. B., . . . Stroke Foundation. Retrieved from: https:// Anderson, R. P. (2009). The Society of Thoracic www.heartfoundation.org.au/images/uploads/ Surgeons 2008 Cardiac Surgery Risk Models: publications/Absolute-CVD-Risk-Full-Guidelines. Part 2- Isolated Valve Surgery. The Annals of pdf Thoracic Surgery, 88(1). 25. Australian Government: Department of Health. 17. Shahian, D. M., Obrien, S. M., Filardo, G., (2009). Reduce Your Risk: National Guidelines for Ferraris, V. A., Haan, C. K., Rich, J. B., . . . Alcohol Consumption [Brochure]. Canberra, ACT. Anderson, R. P. (2009). The Society of Thoracic Surgeons 2008 Cardiac Surgery Risk Models: Part 3—Valve Plus Coronary Artery Bypass Grafting Surgery. The Annals of Thoracic Surgery, 88(1). 18. The Australian and New Zealand Society of Cardiac and Thoracic Surgeons: Cardiac Surgery Database Program (2017). National Annual Report – 2016. Sydney: The Australian and New Zealand Society of Cardiac and Thoracic Surgeons. 19. Kirmani, B. H., Mazhar, K., Saleh, H. Z., Ward, A. N., Shaw, M., Fabri, B. M., & Pullan, D. M. (2013). External validity of the Society of Thoracic Surgeons risk stratification tool for deep sternal wound infection after cardiac surgery in a UK population. Interactive CardioVascular and Thoracic Surgery, 17(3), 479- 484.

Page ii QCOR Annual Report 2017 Heart Failure Support Services Audit 26. Australian Bureau of Statistics (2017). Estimates of Aboriginal and Torres Strait Islander Australians, 2017. Canberra: Australian Bureau of Statistics. 27. Atherton, J. J., Sindone, A., Pasquale, C. G., Driscoll, A., Macdonald, P. S., Hopper, I., . . . Connell, C. (2018). National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018. Heart, Lung and Circulation, 27(10), 1123-1208. 28. Atherton, J. J., & Hickey, A. (2017). Expert Comment: Is Medication Titration in Heart Failure too Complex? Cardiac Failure Review, 03(01), 25. 29. Queensland Health: Statewide Cardiac Clinical Network (2017). Queensland Cardiac Outcomes Registry – 2016 Annual Report. Brisbane: Queensland Government.

QCOR Annual Report 2017 Page iii 59 Glossary

ACC American College of Cardiology MRA Mineralocorticoid Receptor Antagonists ACEI Angiotensin Converting Enzyme Inhibitor MSSA Methicillin-sensitive Staphylococcus aureus ACS Acute Coronary Syndromes NCDR The National Cardiovascular Data Registry ANZSCTS Australian and New Zealand Society of Cardiac NGH Nambour General Hospital and Thoracic Surgeons NOAC Non-Vitamin K Antagonist Oral Anticoagulants ARB Angiotensin II Receptor Blocker NP Nurse Practitioner ARNI Angiotensin Receptor-Neprilysin Inhibitors NRBC Non-Red Blood Cells ASD Atrial Septal Defect NSTEMI Non ST-Elevation Myocardial Infarction BCIS British Cardiovascular Intervention Society PAH The Princess Alexandra Hospital BiV Biventricular PCI Percutaneous Coronary Intervention BMI Body Mass Index PDA Patent Ductus Arteriosus BMS Bare Metal Stent PFO Patent Foramen Ovale BVS Bioresorbable Vascular Scaffold QAS Queensland Ambulance Service CABG Coronary Artery Bypass Graft QCOR Queensland Cardiac Outcomes Registry CCL Cardiac Catheter Laboratory QE II Queen Elizabeth II Jubilee Hospital CH Cairns Hospital QH Queensland Health CHF Congestive Heart Failure QHAPDC Queensland Hospital Admitted Patient Data CI Clinical Indicator Collection CR Cardiac Rehabilitation QIP Quality Incentive Payment CRT Cardiac Resynchronisation Therapy RBC Red Blood Cells CS Cardiac Surgery RBWH The Royal Women’s and Brisbane Hospital CV Cardiovascular RCA Right Coronary Artery CVA Cerebrovascular Accident RHD Rheumatic Heart Disease DAOH Days Alive and Out of Hospital SCCIU Statewide Cardiac Clinical Informatics Unit DEM Department of Emergency Medicine SCCN Statewide Cardiac Clinical Network DES Drug Eluting Stent SHD Structural Heart Disease DOSA Day Of Surgery Admission STEMI ST-Elevation Myocardial Infarction DSWI Deep Sternal Wound Infection STS Society of Thoracic Surgery ECG 12 lead Electrocardiograph TAVR Transcatheter Aortic Valve Replacement eGFR Estimated Glomerular Filtration Rate TMVR Transcatheter Mitral Valve Replacement EP Electrophysiology TPCH The Prince Charles Hospital FdECG First Diagnostic Electrocardiograph TPVR Transcatheter Pulmonary Valve Replacement FTE Full Time Equivalent TTH The Townsville Hospital GCUH Gold Coast University Hospital VCOR Victorian Cardiac Outcomes Registry GP General Practitioner VF Ventricular Fibrillation HF Heart Failure VSD Ventricular Septal Defect HFpEF Heart Failure with Preserved Ejection Fraction HFrEF Heart Failure with Reduced Ejection Fraction HFS Heart Failure Service HFSS Heart Failure Support Service HHS Hospital and Health Service IC Interventional Cardiology ICD Implantable Cardioverter Defibrillator ICD-10 International Classification of Diseases 10th edition IHT Interhospital Transfer IVDU Intravenous Drug Use KPI Key Performance Indicator LAA Left Atrial Appendage LAD Left Anterior Descending Artery LCX Circumflex Artery LOS Length Of Stay LV Left Ventricle LVEF Left Ventricular Ejection Fraction MBH Mackay Base Hospital MI Myocardial Infarction Page iv QCOR Annual Report 2017 60 Upcoming initiatives

• Improved collaboration with the Rheumatic Heart Disease (RHD) Register and Control Program is a key objective in the recently published RHD Action Plan. As of September 2018, rheumatic heart disease is a notifiable condition in Queensland. QCOR will work with the RHD Register to improve the quality and ease of access to related information. The QCOR currently reports to relevant National clinical registries and its currently participating in the development of the National Cardiac Registry and the National Cardiac Rehabilitation Registry. • Cardiac outreach services are delivered to regional and remote sites across Queensland, primarily by staff from large tertiary hospitals. There is limited data about the quality and effectiveness of these services. QCOR will develop and deploy a centralised data collection and reporting module to enhance coordination of services and monitor the care provided to patients residing in rural and remote locations in Queensland. The new QCOR module is anticipated to be in place in early 2019. • The final project for delivery from the tatewideS Cardiac Clinical Network’s Cardiac Information Solutions Program is currently being deployed. The ECG Flash: 24/7 Clinical Advice and ECG Interpretation Service connects clinical staff in rural and remote locations with cardiologists in metropolitan facilities. The system allows rapid inter-hospital clinical interpretation of 12-lead ECG readings and clinical advice for patients with challenging clinical presentation. To date, the system has been deployed in 5 Hospital and Health Services and will be deployed in most services by the end of 2019.

atiet presets i eerec is tae a is iicult to iterpret eote cliicias use Flas solutio epartet it cest pai to reuest a specialist iterpretatio

alls ac te treati cliicia it eceives a eail it a iital cop o call carioloists oile evice specialist avice te a cotact etails receives a alert

Figure C: Concept model for rapid inter-hospital clinical interpretation of 12-lead ECGs (CISP ECG Flash Project)

QCOR Annual Report 2017 Page v Queensland Health Queensland Health

Improvement | Transparency | Patient Safety | Clinician Leadership | Innovation

Statewide Cardiac Clinical Network Queensland Cardiac Outcomes Registry 2017 Annual Report

Clinical Excellence Division Creating solutions for better healthcare